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College  of  ^fjpsiciansi  anJi  burgeons! 
Htbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/cloacalmorphologOOrick 


Cloacal  Morphology  in  its  Relation   to  Genito- 
Urinary  and  Rectal  Diseases. 


(With  54  Plates  and  93   Illustrations.) 


BY 

BENJAMIN  MERRILL  RICKETTS, 
Ph.B.,  M.D.,  LL.D.,  F.A.C.S. 

Member   American   Medical   Association;    (House   Surgeon    N.   Y.    Skin   and   Cancer 
Hospital,    1S84-5);    Ohio    State   Medical    Society;    Western    Surgical    and    Gyneco- 
logical   Association;    International    Medical    Congress,    1887;    International    As- 
sociation   Railway    Surgeons;    Mississippi    Valley    Medical    Association;    Cin- 
cinnati Academy  of  Medicine;  Honorary  Member  Medical  Society  State  of 
New   York;    Honorary   Member   St.   Louis   Medical    Society;    Fellow   New 
York    State    Medical    Association;    Member    Societe    Internationale    de 
Chirurgie;  American  Urological  Association;  American  Proctological 
Society;     Cincinnati     Society    of    Natural    History;     Pan-American 
Congress;  Honorary  Professor  of  Surgery  of  the  Tliorax  and  its 
Viscera;     Barnes    and    American     Medical     Colleges;     National 
University    of    Arts    and    Sciences,    St.    Louis,    Missouri,    and 
Clinical   Congress   of  Surgeons   of  North    America;    Author 
of  Volumes  What  to  Do  in  Case  of  Accident;  Surgery  of 
the    Prostate,    Pancreas,    Diaphragm,    Spleen,    Thyroid 
and  Hydrocephalus,  Surgery  of  the  Ureter,  Surgery 
of    the    Heart    and    Lungs    and    Surgery    of    the 
Thorax  and  Its  Viscera;   Founder  and   Director 
of     the     B.     Merrill     Ricketts     Experimental 
Surgical    Research    Laboratory,     Cincinnati, 
Ohio,    etc.,    etc.,    etc.,    etc.,    etc.,    etc.,    etc. 


CINCINNATI 
1916 


Published  by  the  Author 

MCMXVI. 
(1916.) 


Copyright,     1916, 

by 

Benjamin   Merrill  Ricketts 


This  work  is  dedicatea  to  HOWARD 
AYERS,  B.S.,  Ph.D.,  L.L.D.,  Morpholo- 
gist    and    Advocate    of    Scientific    Research. 


Everything  has  a  beginning,  an  existence, 
and  an  ending,  with  changes  of  equal  interest 
and  importance.  It  is  therefore  necessary  to 
become  famihar  with  creation  that  existence 
and  dissolution  may  be  better  understood. 

The  thing  created  should  be  more  perfect 
than  its  creator,  its  existence  superior  and  its 
dissolution  more  natural,  but  there  are  errors 
and  variations  evidenced  upon  every  hand, 
among  them  changes  in  the  cloaca  which  are 
herein  considered.  (B.   M.   R.) 


INTRODUCTION. 

For  fifteen  years  the  anatomical  relation  of  the  perineum,  coccyx,  uro-genital  and 
rectal  tracts  has  been  attractive  to  me,  especially  symptomatology,  which  so  much  con- 
cerns them  and  which  is  so  much  in  doubt.  But  not  until  a  more  recent  time,  when  the 
importance  of  the  pudic  nerve  and  its  many  changes  in  distribution  resulting  from  changes 
in  the  cloaca  to  4orm  the  perineum  were  suggested,  was  I  convinced  of  the  great  similarity 
of  physiologic  symptoms  due  to  their  anomalies,  diseases  and  injuries,  and  now  at  the  con- 
clusion of  this  research,  I  find  this  thought  crystallized  into  one  more  certain  and  enduring. 

Especial  attention  has  been  given  to  the  pudic  nerve,  lymphatics.  Glomus  coccygea, 
coccyx,  Cowper's  and  Bartholin  glands,  because  they  play  a  more  important  role  in 
symptomatology  than  has  ever  been  ascribed  to  them. 

With  the  exception  of  the  Glomus  and  Coccyx,  no  form  of  treatment  is  considered 
throughout  this  work.  I  have  quoted  freely  from  many  authors,  not  only  in  histology, 
but  in  the  general  text,  because  I  felt  my  incompetency  and  because  time  would  not 
permit  of  a  more  general  research.  If  therefore,  I  have  been  permitted  to  reflect  only 
a  delicate  ray  of  light  upon  this  suggestion,  the  purpose  of  this  work  will  have  been 
served. 

I  desire  to  thank  Dr.  D.  D.  DeNeen  for  his  assistance  in  preparing  the  work  on  the 
lymphatics,  Miss  Gladys  Ayers  and  Hawley  Zwick  for  photographic  illustrations.  Miss 
Ayers  for  copy,  my  students  Miss  Nevada  Hannah  and  Mr.  R.  A.  White  for  assistance 
in  the  preparation  of  the  copy,  Drs.  Sappy,  Cuneo,  and  Marcille,  Deaver,  Piersol,  Kelley, 
Schumacher,  Jakobsson  and  others  for  permission  to  use  illustrations  and  quote  text.  I 
also  want  to  express  my  deep  appreciation  to  Mr.  Howard  Ayers  for  his  contribution, 
valuable  suggestions  and  encouragement  in  this  research,  and  to  the  A.  R.  Fleming  Print- 
mg  Company  for  producmg  the  book  m  a  form  so  pleasing. 

Benjamin  Merrill  Ricketts, 

February  14th,  1915.  N.  W.  Corner  Fourth  and  Broadway, 

Cincinnati. 


Page  Five 


CONTENTS 


Chapter  I. 

Chapter  II. 

Chapter  III. 
Chapter  IV. 

Chapter  V. 

Chapter  VI. 

Chapter  VII. 

Chapter  VIII. 

Chapter  IX. 

Chapter  X. 

Chapter  XI. 

Chapter  XII. 

Chapter  XIII. 

Chapter  XIV. 

Chapter  XV. 

Chapter  XVI. 

Chapter  XVII. 


Introduction. 

A  Summary  of  Development  of  the  Rectum  and  Urogenital 
Sinus  from  the  Cloaca.     Illustrated. 

Perineum. — Anatomy,    Anomalies    Diseases,    Injuries    and 
Symptoms.      Illustrated. 

Definitions. — Of    Etiology,  Symptoms  and  Diagnosis. 

Blood   Vessels. — Anatomy,  Anomalies,   Diseases,   Injuries 
and  Symptoms.     Illustrated. 

Nerves. — Anatomy,    Anomalies,     Diseases,     Injuries    and 
Symptoms.      Illustrated. 

Ly^mphatics. — Anatomy,  Anomalies,  Diseases,  Injuries  amd 
Symptoms.      Illustrated. 

Glomus    Cocc^gea. — Anatomy,   Anomalies,   Diseases,    In- 
juries and  Symptoms.      Illustrated.      Bibliography. 

Coccyx. — Anatomy,    Anomalies,     Diseases,    Injuries    and 
Symptoms.      Illustrated.      Bibliography. 

Urethra. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms.     Illustrated. 

Bladder. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms.      Illustrated. 

Ureters. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms.      Illustrated. 

Kidneys. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms.      Illustrated. 

Erectile   Body. — Anatomy,   Anomalies,    Diseases,    Injuries 
and  Symptoms.      Illustrated. 

Prostate  Gland. — Anatomy,  Anomalies,  Diseases,  Injuries 
and  Symptoms.      Illustrated. 

CoTvper's    Glands. — Anatomy,    Anomalies,    Diseases,    In- 
juries and  Symptoms. 

Testicles. — Anatomy,    Anomalies,    Disecises,    Injuries   and 
Symptoms.      Illustrated. 

Spermatic  Ducts. — .Anatomy,  Anomalies,  Diseases,  Injuries 
and  Symptoms.      Illustrated. 


Page   Sevin 


Chapter  XVIII.      Scrotum. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms.      Illustrated. 

Chapter  XIX.  Vagina. — Anatomy,    Anomalies,    Diseases,     Injuries    and 

Symptoms.      Illustrated.  *^ 

Chapter  XX.  Bartholin    Glands. — Anatomy,    Anomalies,    Diseases,    In- 

juries and  Symptoms.      Illustrated. 

Chapter  XXI.  Clitoris. — Anatomy,    Anomalies,     Diseases,     Injuries    and 

Symptoms.      Illustrated. 

Chapter  XXII.        Uterus. — Anatomy,     Anomalies,     Diseases,     Injuries     and 
Symptoms.      Illustrated. 

Chapter  XXIII.      Ovaries. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms.      Illustrated. 

Chapter  XXIV.      Fallopian  Tubes. — Anatomy,  Anomalies,  Diseases,  Injuries 
and  Symptoms.      Illustrated. 

Chapter  XXV.       Rectum. — Anatomy,    Anomalies,    Diseases,    Injuries    and 
Symptoms. 


Page  Bight 


CHAPTER  1. 


A  Summary  of  the  Development  of  the  Rectum   and    Urinogenital 
Sinus  from  the  Cloaca. 


CLOACAL-COCCYGEAL  HISTORY. 

By 
HOWARD  AYERS. 

N  VERTEBRATE  anatomy  the  term  cloaca  is  applied  to  the 
common  chamber  into  which,  in  many  forms,  the  intestine,  the 
ureters  and  the  genital  passages  discharge. 

Reptiles  and  birds  all  possess  a  cloaca  generally  well  de- 
veloped. Since  both  birds  and  mammals  are  descended  from 
the  reptilian  stock  by  divergent  paths  of  development  we  would 
expect  to  find  traces  of  such  an  important  organ  as  the  cloaca 
in  the  mammals  also. 

Living  in  Australia  today,  we  find  two  primitive  mammalian 
forms,  the  duck-bill  (Ornithorhynchus  paradoxus)  and  the  spiny 
ant-eater  (Echidna  hystrix).  Both  of  them  are  egg-laying  mam- 
mals— laying  eggs  like  a  reptile  or  bird  and  after  hatching  the 
eggs  in  their  abdominal  pouches,  nourishing  the  young  with  a 
milk  secretion  from  rudimentary  or  better — primitive  milk  glands. 
They  are  clearly  transitional  forms  between  the  reptihan  stock 
and  the  mammalian  stock.  These  two  forms  are  classed  as  Monotromes  because 
they  have  only  one  external  opening  for  voiding  the  contents  of  intestine,  ureters  and 
genital  tubes.  They  are  cloacal  mammals  and  the  cloaca  is  preserved  in  reptilian  per- 
fection. While  none  of  the  higher  mammals  normally  possess  a  cloaca  in  the  adult  state, 
all  of  them  pass  through  a  stage  in  embryonic  growth  in  which  the  cloacal  apparatus  is 
fully  developed.  However,  before  the  permanent  condition  is  reached  the  cloaca  is 
generally  obliterated  as  a  common  chamber  and  it  becomes  separated  into  two  tubes,  one 
for  the  reception  of  the  intestine,  the  other  for  the  ureters  and  the  genital  canals. 

This  separation  always  occurs,  except  when  the  developmental  processes  are  in- 
terrupted or  inhibited.  Such  inhibitions  do  occur  and  that  not  infrequently.  They  may 
occur  at  various  stages  in  the  growth  of  the  parts — such  individuals  we  call  abnormal 
— we  can  only  mean  that  there  has  been  an  arrested  or  thwarted  development  of  the 
parts.  For  example,  in  the  human  female  we  occasionally  find  a  double  vagina — a 
normal  marsupial  condition  or  again  we  may  find  the  ancient  and  normal  reptilian. 

In  the  human  male  we  not  infrequently  find  a  condition  of  the  erectile  organ  which 
we  term  hypospadia.  Hypospadia  is  nothing  more  or  less  than  the  normal  condition  of 
the  erectile  organ  in  the  Monotromes.  Various  other  conformations  which  we  call 
deformations  when  we  find  them  in  man  are  simply  due  to  the  persistence  of  normal  con- 
ditions of  the  parts  as  found  in  ancestors  of  the  stock. 

The  persistence  is  due  to  some  check  in  the  evolutionary  growth  of  the  human 
individual. 

Let  us  now  examine  the  embryology  of  the  cloacal  region  in  man. 


Page  Nine 


In  the  human  embryo  of  fifteen  days'  growth,  the  cloaca  is  well  formed.  The 
opening  of  the  urinogenital  sinus  and  the  intestine  are  still  confined  to  the  common  cham- 
ber. The  cloacal  tubercle  is  prominent  and  lies  in  the  center  of  the  quadrangle  formed 
by  the  leg  pads,  the  coccygeal  tubercle,  and  the  umbilical  cord.     Soon,  however,  changes 


€t£ctac 

^Ureter 

■OVi'iu.d'- 


Cloa£ctl       \ 


rtMettWl 


Plate    1 . — Evolution    of    the    Cloaca. 

begin  in  the  cloacal  aperture  into  the  definitive  anus  and  the  urino-genital  sinus  or  pore. 
Two  folds  of  the  lateral  walls  of  the  cloaca  grow  towards  each  other,  until  they  meet 
and  coalesce,  thus  forming  the  perineum.  The  proctodaeum  breaks  through  into  the 
lumen  of  the  gut,  and  the  cloaca,  as  such,  is  no  more.     These  changes  are  completed 


'       oviciujcT  . 


S. 


Cloacal 


Plate    2 — Evolution    of    the    Cloaca. 
Page   Ten 


about  the  end  of  the  fifth  week.  I  here  is,  however,  a  short  time  during  which  the 
human  embryo  possesses  a  true  cloaca. 

We  have  spoken  only  of  the  walls  of  the  cloaca.  Of  course  all  other  structures  such 
as  blood-vessels,  nerves,  and  muscles  are  involved  in  these  transformations,  so  that  in 
the  study  of  the  cloacal  region  of  the  adult  human  we  must  bear  in  mind  that  all  the 
structures  have  an  ancient  pedigree.  For  example  the  old-time  Musculus  Sphincter  Cloacae 
is  separated  into  M.  sph.  Ani.  Ext.  and  M.  sph.  Urogenitalis. 

The  nervous  pudendus  breaks  up  into  branches  supplying  the  lower  rectum  and  anus 
and  urethra  and  erectile  organs,  each  branch  receiving  an  appropriate  name  in  the  ter- 
minology of  human  anatomy. 


1 


Tall. 


Fig.    2. —Tailed  Man. 


Jk-  ■ 


|i\^>V*s'-^- 


Fio.  3 Cloaca  of  Rabbit.  Fig.  4. — Showng   tail    extended.      {Johns    Hopkins   Bulletin.) 


(    ].      M.  Sph.  Ani.  Ext. 

M.  Sph.  Cloaca     ',  ">     a.  M.   bulbo  cavernosas 

j  j  (a)      M.  transversus  perinei. 

^    2.      M.  Sph.  Urogenit.     '  (b)     M.  urethralis. 

b.  M.  ischio  cavernosas. 


In  the  rabbit  for  example,  we  have  an  intei mediate  stage  in  the  separation  of  the 
cloacal  muscle  into  its  parts — for  here  the  division  is  not  complete  and  neither  sphincter 
forms  a  ring — but  the  two  together  an  open-jointed  figure  eight. 


Page  Eleven 


The  cloacal  muscles  are  fastened  more  or  less  strongly  to  the  coccygeal  vertebrae 
and  thus  these  skeletal  parts  play  an  important  part  in  the  functionmg  ot  the  cloacal 


organs. 


Coccpx.— In  the  mammals  the  tail  vertebrae  range  m  number  from  49  (Mams 
Macrura)  to  3  to  5  as  in  the  anthropoids  and  man.  ^u,  ,  1 

However,  in  embryonic  stages  (4  to  1 2  M.  M.)  man  has  as  many  as  eight  tail 
segments  with   the   notocord  projecting  beyond   them,    mdicatmg   a   still   larger   number 


Fis.  3. — Ventral  surface  of  tail.      {Johns  Hopkins  Bulletin.) 


Fig.    6. — Showing   contracted    tail.      {Johns    Hopkins    Bullelin.) 


in  the  ancestral  stock  from  which  the  human  species  has  descended.     They  form  a  true 

external  tail.  _  ,  ,       .  ,  ^      ,. 

The  coccyx  is  not  a  stable  group  of  bones  but  is  on  the  way  to  disappearance. 

This  is  vividly  shown  by  the  reduction  of  the  typical  external  tail  of  the  human 
embryo  so  that  by  the  time  adult  Ufe  is  reached  there  is  ordinarily  no  trace  of  the  ex- 
ternal tail  and  the  internal  tail  is  a  mere  rudiment  attached  to  the  tip  of  the  sacrum. 

Now  and  then  the  external  tail  is  not  reduced  and  we  have  a  genuine  tailed  man. 

Pasre  Twelve 


From  an  examination  of  the  coccygeal  bones  in  the  adult  we  might  suppose  that  they 
represented  the  bodies  only  of  the  caudal  vertebrae  but  embryology  shows  us  that  is 
not  the  case. 

During  development  they  possess  membranous,  and  in  the  case  of  the  first  and 
second  coccygeal  vertebrae,  cartilaginous  neural  processes. 

The  articular  and  transverse  processes  are  incomplete  or  entirely  lacking.  Although 
separate  centers  are  developed  for  the  rib  rudiments  they  do  not  mature  as  such. 

Even    the    haemal    processes    appear    in    membranous    form    (3rd    to    5th    month) 


Fig.  7. — Front- 
al section  of  tail, 
showng  the  ar- 
rangement of  the 
muscle  fibers  (M). 
a.  Place  from 
%vhlch  the  cross- 
section  represent- 
ed in  Fig.  5  was 
taken.      X3. 


Fig.  8. — Cross-section  through 
the  middle  of  the  tail  (Fig.  4, 
a).  M,  muscle;  M',  degenerat- 
ing muscle;  A,  artery;  A^, 
nerve;  L  is  placed  on  the  left 
and  R  on  the  right  of  the 
appendage.      X  9. 


Fig.  9. — Caudal  region  of  embryo  of 
14  mm.  (No.  144  of  Dr.  Mall's  collec- 
tion), combined  from  several  sagittal  sec- 
tions. An.,  anus;  Ao.,  caudal  aorta  {A. 
sacralis  media);  Ca.  fil.,  caudal  filament; 
Ch.,  notochord;  Med.,  medullary  cord; 
5.  u§.,  sinus  urogenitalis ;  V.  32,  third 
coccygeal  vertebra;  36,  seventh  coccygeal 
vertebra;  V.  c.  i.,  caudal  portion  of  vena 
cava   inferior    (F.  sacralis   media).     X91. 


to  disappear — leaving  no  trace  in  the  adult.  From  these  bare  facts  we  can  recognize  the 
true  vertebral  nature  of  the  coccygeal  bones  as  vestigeal  structures — the  remains  of  com- 
plete vertebrae  in  the  ancestral  stock  of  the  human  species.  The  facts  set  forth  in  this 
brief  sketch  point  unmistakably  to  the  conclusion  that  the  cloacal-coccygeal  territory 
has  suffered  extensive  transformation  in  its  descent  to  the  human  condition  and  to  the 
further  conclusion  that  it  is  still  undergoing  change  and  reduction.  The  practitioner  as 
well  as  the  surgeon,  should  have  a  thorough  knowledge  of  the  phylogenetic  as  well  as 
the  ontogenetic  history  of  the  region  in  order  to  deal  intelligently  with  the  normal  and 
abnormal  structure  and  functions  of  the  parts. 


Page  Thirteen 


CHAPTER  II. 


PERINEUM. 
ANATOMY. 


"■-.BUcldt. 

1* 

\ci,n',,-. 

IU«M. 

J 

D.j.itl  .,CT  cfcl.t;-.! 

I,mi.<,    lu....        I 


Fig.    10. — Female    pelvis    and    perineum — sagittal    section  Fig.     II. — Male     pelvis     and     perineum — sagittal     section 

(Deaver).  (Deaver). 

Anatomy  of  the  Perineum. 

Superficial  and  Deep   Tissues  of  the  Perineum. 

Superficial. 

Cutaneous. 


Fat. 

Fascia,  superficial  and  deep. 

Blood  vessels. 

Nerves. 
Lymphatics. 


Page  Fourteen 


Deep. 


1 .  Sphincter  ani  externus. 

2.  Transversus  perinei  superficialis. 

3.  Bulbo  cavernosus — or  Erector  penis  and  clitoris. 

4.  Ischia  cavernosum. 

5.  Compressor  Urethrae,  beneath  the  triangular  Hgaments. 


Fig.    12. — Superficial   fascia   of  male  perineum    (Deaver). 

HE  PERINEUM  is  of  recent  origin  in  the  history  of  animal  life 
and  found  only  in  mammals,  being  absent  in  fish,  reptiles  and 
birds  and  as  has  been  stated,  absent  in  a  few  mammals,  for  ex- 
ample the  rabbit. 

The  perineal  body  lies  between  the  vagina  and  rectum 
with  the  base  pointing  downward,  one  inch  antero-posterior  in 
diameter  and  one  one-half  inches  in  height,  but  it  may  vary  in 
size  in  individuals  of  the  same  kind.  In  the  male  it  is  sup- 
plied by  the  internal  pudic  and  inferior  hemorrhoidal  vessels; 
while  in  the  female  the  blood  supply  is  from  the  iliac  artery. 
It  is  inhibited  by  the  pudic  and  small  sciatic  or  pudendal  nerves 
and  its  lymphatics  empty  into  the  inguinal  glands. 

There  is  no  part  of  the  body  possessing  so  great  a  variety 
of  organs  and  tissues  as  the  perineum  and  its  intimately  asso- 
ciated structures. 
Tissues  and  organs  entering  into  the  structure  of  and  most  concerned  in  the  forma- 


Page  Fifteen 


tion  of  the  perineum,  anj'  one  of  which  by  reason  of  anomaly,  disease  or  injury,  may 
cause  subjective  symptoms  alone  or  combined,  because  of  insult  to  one  or  more  branches 
of  the  pudic  nerve,  are  classified  as  follow^s : 


Perineum 

Coccyx 

Urinary 

Genitalia 

Rectum 

Cutaneous 

Fat 

Fascia 

Bone 

Periostium 

Glomus-Coccygea 

Urethra 
Bladder 
Ureters 

Male 
Penis 
Prostate 

Sphincter  ani 

Rectum 

Sigmoid 

Muscles 

Kidneys 

Cowper's    glands 

Tendons 
Ligaments 
Bones 
Blood  vessels 

Testicles 
Spermatic   ducts 
Scrotum 

Nerves 
Lymphatics 

Female 
Vagina 

Bartholini  glands 
Clitoris 
Uterus 
Ovaries 
Tubes 

Cutaneous  structures  reveal  as  objective  the  presence  of  induration,  tenderness,  color, 
and  subjective  such  as  pain,  location,  temperature,  loss  of  appetite,  general  depression  and 
reflected  pain,  distal  to  the  perineum. 

Fat  is  deposited  within  the  integument  and  external  to  the  superficial  fascia  and 
more  or  less  about  the  muscles. 

The  fascia  in  the  perineum  is  both  superficial  and  deep. 

The  superficial  is  a  continuation  of  the  superficial  fascia  of  the  abdominal  wall, 
thigh  and  buttocks  and  extends  over  the  pelvis  and  scrotum.  In  the  scrotum  it  is  in- 
termingled with  involuntary  muscular  fibers  and  forms  the  dartos  muscle  which  assists 
in  suspending  the  testicles  and  corrugating  the  skin  of  the  scrotum.  It  also  forms  the 
septum  of  the  scrotum  which  separates  the  testicles. 

The  fascia  over  the  posterior  portion  of  the  perineum  fills  up  the  ischio-rectal  fossae 
in  the  form  of  two  pads  of  adipose  tissue  on  either  side  of  the  rectum  and  anus,  while 
the  fascia  of  the  anterior  part  of  the  perineum  resembles  the  same  fascia  in  the  groin. 
The  deeper  layers  are  attached  to  the  pudic  arch  posteriorly  to  the  base  of  the  triangular 
ligament  and  in  the  middle  line  to  the  root  of  the  penis  (bulbus  and  corpus  spongioseum) 
and  median  line  of  the  scrotum.  The  fascia  is  continued  anteriorly  over  the  spermatic 
cords  to  the  anterior  abdominal  wall,  and  its  function  is  to  prevent  pus  and  extravasated 
urine  passing  backwards  into  the  ischio  rectal  fossa  or  laterally  into  the  thigh.  It  is 
directed  forward  into  relation  with  the  scrotum  and  penis  and  along  the  spermatic  cord 
to  the  anterior  abdominal  wall.  The  septum  of  the  scrotum  being  incomplete,  fluid  ex- 
travasated on  one  side  according  to  Cunningham  can  pass  across  the  middle  line  to  the 
opposite  half  of  the  perineum  and  scrotum. 

The  deep  fascia  of  the  perineum  is  only  a  delicate  aponeuroses  of  the  muscles. 

The  superficial  perineal  arter})  arises  in  the  anterior  part  of  the  ischio  rectal  fossa, 
pierces  the  base  of  the  triangular  ligament,  and  divides  into  long  slender  branches  (scrotales 
in  the  male,  labiales  posteriores  in  the  female)  which  are  continued  forward  in  the 
urethral  triangle,  beneath  the  superficial  perineal  fascia,  to  the  scrotum.  It  anastomoses 
with  its  fellow  of  the  opposite  side,  with  the  transverse  perineal  and  the  external  pudic 
arteries,  and  supplies  the  muscles  and  subcutaneous  structures  of  the  urethral  triangle. 

The  superficial  transverse  perineal  muscle  is  not  always  present  in  the  form  of  a 
small  delicate  bundle  of  fibres  arising  from  the  ascending  ramus  of  the  ischium  and  the 
fascia  over  it,  and  forms  the  base  of  the  triangular  ligament.     It  is  directed  inwards  and 

Page  Sixteen 


forwards  to  be  inserted  into  the  central  point  of  the  perineum  and  conceals  the  base  of  the 
triangular  ligament. 

The  transverse  perineal  artery  is  a  small  branch  which  arises  either  from  the  internal 
pudic  or  from  its  superficial  perineal  branch.  It  runs  inward  along  the  base  of  the 
triangular  ligament  to  the  central  point  of  the  perineum,   where  it   anastomoses  with  its 


-Mijl 


Fig.    13. — Superficial    dissection    of    the    perineum    (Kelley), 


f 


\y 


Fig.     14. — Deep    dissection    of    the    perineum    (Kelley). 
Page  Seventeen 


fellow  on  the  opposite  side,  with  the  superficial  perineal  branch  and  with  the  interior  hemor- 
rhoidal arteries.     It  supplies  the  sphincter  vaginae,  and  the  anterior  fibers  of  the  levator  ani. 

The  nerve  supply  is  from  the  perineal  branches  of  the  pudic  nerve  and  its  function 
is  to  assist  the  deep  transverse  perineal  in  fixing  the  central  tendon  of  the  perineum  during 
the  contraction  of  the  bulbo  cavernosi. 

The  transverse  perinei  profundi  muscle  arises  from  the  ascending  ramus  of  the 
ischium  just  below  the  compressor  urethra  and  is  inserted  into  a  median  raphe,  continues 
with  that  of  the  compressor  urethra  in  the  form  of  two  separate  bundles  of  fibers  one 
below  and  the  other  behind  the  compressor  urethra.     Its  function  is  to  fix  the  central  tendon 


Fig.    15. — Triangular    ligament    and    superficial    perineal  Fig.  16. — Ischio-rectal  fossae  and  fascia  of  colles  of  male 

interspace  of  female   (Deaver).  perineum    (Deaver). 

of  the  perineum  during  the  contraction  of  the  bulbo  cavernosus.     Some  of  its  fibers  unite 
with  those  of  the  superficial  transverse  perineal  muscle. 

Its  nerve  supply  is  by  a  branch  of  the  pudic  which  breaks  up  into  many  fine  twigs, 
branches  of  the  fourth  sacral  nerve. 

Deep  muscles  of  the  pelvic  floor. 

1.  Levator  ani.     (See  rectum.) 

2.  Obturator  internus. 

3.  Pyriformis. 

4.  Coccygeus.      (See  coccyx.) 

Obturator  Internus  arises  by  fleshy  fibers  on  the  pelvic  aspect  of  the  hip  bone  and 
posteriorly  opposite  the  small  sciatic  notch  and,  like  the  obturator  externus,  is  fan-shaped. 


Page  Eighteen 


0«ncl  *  tf  ^*<>\ 


Supflifkial  laysr  af  tr<angul»r  1.^ 

Bulb  o1  co'put  tfJong.o^Ki 


Fig.   17. — Superficial  muscles,  arteries  and  nerves  of  male  Fig.   18. — Superficial  layer  of  triangular  ligament  of  male 

perineum    (Deaver) .  perineum   (Deaver) . 


Fig.  19. — Muscles  in  floor  of  pelvis — superior  view  (Deaver).  Fig.    20. — Triangular    ligament    and    compressor    urethras 

muscle    (Deaver). 


Page  Nineteen 


It  is  separated  from  the  pelvic  contents  above  by  the  peritoneum  and  below^  by  the  base 
of  the  ischio-rectal  fossa  and  is  crossed  by  the  internal  pudic  vessels  and  nerve  in  the 
outer  wall  of  the  fossa  in  a  special  sheath  of  fascia. 

Piriformis  muscle  arises  within  the  pelvis  between  the  first,  second,  third  and*^fourth 
sacral  vertebrae,  and  from  the  adjacent  part  of  the  bone  external  to  the  anterior  sacral 
foramen.  Passing  out  through  the  great  sacro  sciatic  foramen  it  receives  an  origin  from 
the  upper  margin  of  the  great  sciatic  notch  of  the  ilium  and  from  the  pelvic  surface  of  the 
great  sacro  sciatic  ligament,  forming  in  the  buttocks  a  round  tendon  which  is  inserted  into 
a  facet  on  the  upper  border  and  inner  aspect  of  the  great  trochanter  of  the  femur  partly 
surrounding  the  insertion  of  the  obturator  internus.  It  lines  the  posterior  wall  of  the  pelvis 
lying  behind  the  rectum  and  is  covered  by  a  thin  layer  of  the  parietal  pelvic  fascia.  It  is 
a  muscle  of  abduction  and  flexion. 

The  first  and  second  sacral  nerves  supply  the  pyriformis  muscle  which  arises  from 
the  sides  of  the  sacrum  between  the  first,  second  and  fourth  foramina,  and  which  is  in- 
serted in  the  upper  margin  of  the  great  trochanter. 


ETIOLOGY. 


Dis 


r 


Anomalies. 

Benign. 

Malignant. 


^  Injury. 


ANOMALIES. 


NOMALIES  may  be  congenital  or  acquired,  primary  or  second- 
ary, single  or  multiple,  absent  in  part  or  entirely,  the  result  of 
defective  development,  accident  or  design  and  involve  any  of 
the  adjacent  tissues  or  cavities. 

The  causes  of  symptoms  relating  to  the  perineum,  like 
those  in  other  regions,  may  be  physical  or  functional  and  of 
anomalous,  pathologic  or  traumatic  origin.  It  is  therefore  neces- 
sary to  review  them  briefly  that  their  relations  may  be  better  un- 
derstood, and  because  the  object  of  this  work  is  to  associate 
physiologic  symptoms  and  their  respective  causes,  such  as  pertain 
to  the  perineal  tissues  and  their  intimate,  associated  organs,  it 
will  be  necessary  to  consider  them  separately. 

Anatomical  variations  may  be  due  to  defective  embryonic 
development  or  defective  development  after  birth,  the  result  of 
paralysis,  disease,  injury  or  surgical  operation. 
Variations  from  normal  in  the  soft  structures,   may  be  of  such   a  character  as  to 
partially  or  completely  destroy  mechanical  function,  such  as  urination,  defecation,  impreg- 
nation and  delivery  of  the  products  of  impregnation. 

They  may  also  destroy  physiologic  functions  which  result  from  defective  blood, 
nerve  and  lymphatic  supply  and  bony  structures,  like  the  coccyx,  sacrum  and  pelvis,  may 
possess  such  mechanical  defects. 

Any  one  or  all  of  these  will  cause  symptoms  varying  in  character. 
Pathologic  changes  result   from  acute  or  chronic  diseases,   due  to  infection   or  ac- 
cidental or  induced  trauma. 

Conditions   of   any  character  in   any   of   the  perineal  structures   or   organs   produce 

symptoms  which  may  or  may  not  be  significant  with  or  without  recognition  of  the  lesion. 

Physiologic  changes  may  be  due  to  anatomic,   pathologic  or  traumatic  conditions, 

one  or  all  combined,  or  they  may  be  due  to  changes  in  the  nervous  system  independently. 

Defective   blood,  nerve  and  lymphatic  supply  not  infrequently  disturbs  physiologic 

function.      Secretion  and  excretion  may  be  increased  or  diminished  in  amount  and  then 


Page  Twenty 


materially  changed  and  remain  unrecognized.  This  function  may  be  affected  for  a 
few  minutes  or  it  may  be  hours,  days,  weeks  or  months  or  it  may  be  permanent. 

Traumatic  changes  are  the  result  of  repair  following  infections  and  accidental  or 
surgical  injuries. 

They  occur  quite  frequently  with  more  or  less  loss  of  tissue  and  function  due  to 
cicatricial   tissue. 

This  is  especially  exemplified  with  injury  to  the  penis  and  testicles  with  their  asso- 
ciated ducts  and  the  uterus  with  its  appendages. 

Surgical  operations  may  change  anatomical  relations  with  or  without  interfering 
with   function. 

Such  trauma  for  the  correction  of  anomalies,  diseases  or  injuries  is  not  without  its 
effects,  and  while  it  is  often  necessary,  the  degree  of  restoration  to  normal  varies,  occa- 
sionally it  fails,  while  in  others  it  is  only  a  partial  success,  but  fortunately  the  great 
majority  are  complete  restorations  or  as  near  to  normal  as  it  is  possible  to  obtain,  but  in 
either  event  certain  symptoms  may  result. 


DISEASES. 

Benign.      Malignant. 

BENIGN. 

Papillomata  may  be  congenital  or  acquired,  primary  or  secondary,  usually  pedun- 
culated, single  or  multiple,  vary  in  size,  shape  and  location,  cease,  continue  to  grow,  dis- 
appear spontaneously,  upon  the  mucous  or  cutaneous  surfaces  and  more  frequently  at  or 
near  the  muco-cutaneous  border. 

(See  for  all  chapters,  Papillomata  and  Adenomata:  Historical  Review  (Ricketts), 
Amer.  Jour,  of  Dermatology,  March  and  April,  1908.  Also  N.  Y.  Med.  Jour.,  Vol. 
LXXX,  1907.) 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape  and  in  any  portion  or  tissue  of  the  perineum. 

Tuberculosis  may  be  primary  or  secondary,  single  or  multiple,  acute  or  chronic,  in 
any  tissue  or  portion  of  the  perineum,  probably  more  frequent  at  the  vaginal  or  anal  border, 
cease  or  continue  to  destruction,  or  disappear  spontaneously. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  vary  in  size  in  the  superficial  or  deep  perineum,  more  frequently  primary, 
in  the  form  of  a  chancre.  The  primary  form  occurs  more  frequently  in  the  female  than 
the  male  perineum,  because  of  the  additional  amount  of  mucous  membrane  in  the  fe- 
male, but  it  may  occur  in  any  of  the  perineal  structures. 

Osteomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, vary  in  size  and  location. 

They  seldom  occur  in  the  perineum  except  when  they  originate  in  the  periosteum 
or  the  attachments  of  tendons,  and  are  usually  single,  round  or  irregular  in  shape. 

Chondromala  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, vary  in  size  and  location,  characterized  by  their  development  from  cartilaginous 
tissue,  found  in  the  attachments  of  tendons,  about  bony  structures,  and  almost  invariably 
single. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  vary  in  size  or  location,  and  result  from  degeneration  of  any  neoplasm  or  in- 
jury. Those  congenital  may  be  dermoid  or  contain  blood,  pus,  or  serum,  and  the  ac- 
quired contain  fluids  of  the  same  character,  and  echinoccocci.  Any  variety  may  rupture 
externally,  into  the  vagina,  rectum,  bladder,  uterus,  urethra,  or  peritoneal  cavity. 

Page  Twenty-One 


Fistulae  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
single  or  multiple,  vary  in  size,  length  and  location,  irregular  in  their  course,  traverse  the 
superficial  or  deep  perineal  structures,  originate  in  them  and  open  upon  the  cutaneous 
structures  after  having  connected  the  rectal,  vaginal,  uterine,  peritoneal  cavity,  or  urinary 
tract,  one  or  all,  at  the  same  time.  One  or  more  channels  may  connect  vs'ith  one  tJpening 
v^ithout  either  of  these  tracts  being  involved. 

MALIGNANT. 

Carcinomaia  may  be  primary  or  secondary,  single  or  multiple,  usually  primary  and 
single  in  any  tissue  or  portion  of  the  perineal  body. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple,  usually  primary  and 
single,  in  any  portion  or  tissue  of  the  perineum. 

INJURIES. 

Lacerations,  incisions,  punctures,  contusions  are  the  result  of  accident  or  design, 
may  be  primary  or  secondary,  single  or  multiple,  complete  or  incomplete,  with  ragged  or 
sharply  defined  edges,  complicate  the  rectum,  vagina,  uterus,  urethra,  bladder,  prostate, 
peritoneal  cavity  or  any  of  their  associated  structures. 

Foreign  bodies  may  be  made  to  enter  the  perineum  by  accident  or  design,  from 
without  or  through  the  rectum  or  vagina,  remain  indefinitely,  by  becoming  encysted,  or 
escape  through  the  cutaneous  structures  into  the  urethra,  bladder,  rectum,  vagina,  uterus 
or  peritoneal  cavities. 

SYMPTOMS. 

S^mptomatically  the  perineum  is  perhaps  first  in  interest  in  non-visceral  anatomy,  be- 
cause of  the  numerous  conditions  within  the  urogenital  and  rectal  tracts,  three  of  the  most 
important  channels  within  the  realms  of  surgery.  The  intimate  relations  of  these  organs 
during  the  cloacal  period  and  their  separation  by  the  formation  of  the  perineum,  which 
wrought  so  many  anatomical  changes,  continues  to  be  of  interest  worth  while,  especially 
because  the  purport  of  certain  nervous  impulses  is  yet  undetermined. 

To  symptomatology  will  credit  probably  be  given  for  whatever  great  advance  is  made 
within  the  next  decade  in  the  correction  of  beginning  changes. 

Three  teachings  of  pathology  within  seventy-five  years  and  as  many  of  physiology, 
would  indicate  their  great  uncertainty  and  difference  between  living  and  dead  pathology 
and  that  physio-symptomatology  would  seem  most  likely  in  importance. 

Symptoms  must  be  determined  and  classified  before  an  advance  can  be  taken, 
whether  they  be  due  to  anatomical,  pathological,  physiological,  or  traumatic  conditions. 
Anatomical  are  first  and  most  important  to  know,  before  the  cure  of  those  pathologic  _or 
physiologic  are  attempted  with  any  assurance  of  success.  Those  physiologic  are  de- 
pendent upon  anatomic,  pathologic  and  traumatic  conditions,  one  or  all  combined. 


Page  Twenty-Two 


CHAPTER  III. 


Etiology.     Symptoms.     Diagnosis. 

GOULD'S  DEFINITIONS. 

TIOLOGY  is  the  science  of  efficient  causes." 

"'Anomaly.  Any  deviation  from  the  normal  or  typical 
structure  or  occurrence.  It  may  be  congenital  or  acquired,  ac- 
cidental or  induced." 

''Disease.  A  condition  of  the  body  marked  by  inharmo- 
nious action  of  one  or  more  of  the  various  organs,  owing  to 
abnormal  conditions  of  structural  change." 

''Injur]).  Any  damage  or  harm  to  the  body  or  any  of 
its  parts." 

SYMPTOMS. 

GOULD'S  DEFINITIONS. 

Semieology)  is  the  science  of  signs ;  in  medicine  of  the 
symptoms  of  disease. 

Symptom.  A  coincident  happening,  change  or  phase  vv^hich  occurs  synchronously 
with  a  disease  and  serves  to  point  out  its  nature  and  location. 

Indirect  Symptom.     One  only  indirectly  due  to  disease. 

Negatively  Pathognomonic.  One  which  occurs  in  a  certain  disease  and  therefore 
by  its  absence  shows  the  absence  of  that  disease. 

Pathognomonic  Symptom.  Is  one  which  exhibits  itself  only  in  a  certain  disease  and 
therefore  undoubtedly  proves  itself. 

Physical  Symptoms.     Are  the  physical  signs  of  morbid  conditions. 

Static  Symptom.  Is  one  which  indicates  the  condition  in  a  single  organ  without 
reference  to  the  rest  of  the  body. 

Subjective  Symptom.     Is  that  observed  only  by  the  patient. 

Objective  Symptom.     Is  one  observed  by  the  physician. 

The  Sympathetic  Symptom.  One  for  which  no  adequate  cause  can  be  given,  other 
than  so-called  sympathy. 

Symptoms. 


Tenderness. 
Tumefaction. 
Color. 
Trauma. 
Rigidity. 

Temperature  variation. 
Local  Symptoms. 

Tenderness   is   one   of  the  first  indications   of  pathology   or   irregularity,   best   de- 
termined by  the  sense  of  touch,  but  does  not  always  indicate  the  degree  of  affection. 


1. 

Local. 

2. 

General. 

Local. 
1 

1 . 

2. 

3. 

4. 

5. 

6. 

Page  Twenty-Three 


Tumefactions  are  not  always  perceptible  to  the  eye,  especially  when  the  deep  struc- 
tures are  involved,  but  when  they  are  within  the  cutaneous  structures  they  can  usually  be 
observed.  Palpation  will  reveal  growth  of  ordinary  size  situated  within  the  deeper  struc- 
tures and  they  may  be  recognized  visually,  this  depending  upon  their  size.         ^ 

Color.  The  cutaneous  structures  may  ofttimes  be  discolored  and  its  character  may 
aid  materially  in  determining  conditions. 

Trauma  of  the  perineal  body  is  quite  common  and  it  may  be  inflicted  from  within 
or  without,  or  the  two  sources  combined.  It  is  only  the  more  superficial  wounds,  the  char- 
acters of  which  may  always  be  determined  by  visual  inspection  alone. 

Rigidity  may  occur  in  any  muscular  tissue,  especially  that  for  sphincteric  purposes, 
such  as  is  found  about  the  rectum,  vagina,  urethra  vesicle  openings  of  the  ureters,  cervix 
uteri  and  Fallopian  tubes.  In  fact  nearly  all  of  the  muscular  fibers  found  in  the  perineal 
tissues  and  their  associated  organs  are  of  this  character,  for  the  purpose  of  relaxation  and 
contraction  that  matter  may  be  received  and  expelled  through  them. 

The  function  of  contraction  is  probably  more  important  in  man,  because  of  his 
erect  posture,  especially  at  the  conclusion  of  the  act  of  urination  and  defecation,  both  of 
which  necessitate  a  more  complete  closure  of  the  opening. 

Temperature  may  be  local  and  very  several  degrees  below  to  the  maximum  above 
normal.  When  the  general  temperature  is  high,  the  local  temperature  may  be  normal 
or  subnormal.  This  variation  is  more  easily  determined  when  the  lesion  is  situated  in  the 
hands  and  lower  extremities,  especially  the  feet. 

General  Physiologic  Symptoms. 


1. 

Pain. 

2. 

Chill. 

3. 

Temperature, 

4. 

Lymphatic. 

5. 

Cardiac. 

6. 

Gastric. 

7. 

Perspiration. 

8. 

Respiration. 

9. 

Alimentary. 

10. 

Nervous. 

11. 

Cephalalgia, 

12. 

Delirium. 

13. 

Convulsions. 

14. 

Coma. 

15. 

Shock. 

Pain  and  irregular  growth  probably  rival  in  importance  all  other  symptoms,  the  first 
being  subjective  and  the  second  objective,  one  described  by  the  patient,  the  other  ob- 
served by  the  attendant. 

Pain  thus  being  of  such  importance  must  necessarily  be  attributed  to  involvement  of 
the  nerves,  where  many  branches  of  the  pudic  nerve  are  to  be  found. 

The  severity  of  pain  does  not  always  increase  or  diminish  the  pulse  rate,  even  with 
the  most  severe  lesions,  but  when  the  rate  is  rapid  and  feeble,  serious  conditions  may  be 
suspected.  This  may  also  be  said  of  the  pulse  when  it  is  slow,  full  and  bounding  in 
character. 

Pain  of  any  degree  may  always  be  considered  a  symptom,  though  nervous  tissue 
be  not  pathologic.  The  causes  of  painful  disturbances  are  indeed  numerous,  therefore 
difficult  to  classify.  Pain  may  be  of  local  origin  or  reflected,  for  example  when  pain  is 
present  in  the  distal  end  of  the  penis,  due  to  the  presence  of  a  vesical  calculus. 

Chill  usually  occurs  soon  after  infection  but  may  be  the  result  of  shock  and  vary  in 
degree  from  mild  to  severe,  and  of  but  a  few  minutes'  duration,  though  it  may  continue 
for  several  hours  without  bacterial  infection. 

Temperature  may  vary  from  95  to  106  degrees  F.,  due  to  many  causes,  local  or 
general,  continued  or  remittent,  regular  or  irregular  in  course,  and  of  short  or  long  dura- 
tion. It  would  seem  at  times  to  exist  without  infection  when  it  rises  suddenly  to  I  05 
degrees  or  more,  following  the  introduction  of  a  urethral  sound,  for  it  will  then  disappear  as 
suddenly  as  it  appeared. 

It  may  be  confined  to  certain  localities,  among  them,  the  perineum  and  its  imme- 
diate, related  organs  and  tissues  or  when  general,  affect  the  entire  body. 

Page  Twenty-Four 


L'^mphatics.  There  may  not  be  any  evidence  of  lymphatic  disturbances  though 
they  probably  exist,  because  it  is  difficult  to  understand  how  pathology  of  any  character 
can  exist  in  the  perineal  region  without  affecting  their  normal  status. 

Cardiac  disturbances  are  always  manifested  in  the  arterio-vascular  system,  and  they 
may  vary  from  mild  to  severe,  regular  or  irregular,  slow  or  rapid,  or  the  radial  pulse  may 
be  absent  with  the  presence  of  severe  shock. 

Gastric.  There  may  be  severe  or  mild  stomach  disturbances  such  as  nausea,  acidity, 
vomiting  or  eructation  of  gas. 

Perspiration  is  due  to  varying  degrees  of  heat  produced  from  without  or  within  the 
body.  When  within,  infection  and  cardiac  stimulation  are  the  exciting  causes,  while  the 
external  cause  is  excessive  heat  or  exercise.  It  may  be  due  to  nervous  irritation  of 
any  character. 

Respiration  is  usually  increased  with  the  presence  of  infection,  but  it  may  be  in- 
creased or  diminished  without,  as  when  nervous  irritability  or  severe  pain  is  present. 
Increased  respiratory  movements  are  usually  manifested  when  infection  is  severe  and  pro- 
portionate with  its  degree. 

Such  disturbances  are  not  manifested  to  any  considerable  degree,  except  when  the 
lesions  or  infection  have  become  well  advanced,  then  rapid,  irregular,  deep  or  shallow 
breathing  sometimes  accompanied  by  sighing  is  in  evidence. 

These  respiratory  changes  may  occur  as  the  result  of  neurosis  independently  or  the 
two  factors  combined. 

Such  disturbances  are  more  frequent  with  aggravated  conditions  of  the  bladder, 
ureters  and  kidneys  and  because  of  their  relation  and  close  proximity  to  the  diaphragm 
and  other  important  structures  and  organs,  especially  the  intimate  association  of  the  renal 
sensory  nerve  fibers  with  those  of  the  diaphragm. 

Alimentary  disturbances  such  as  nausea  and  vomiting  are  not  unusual  and  they  may 
be  mild  or  severe,  without  indicating  serious  conditions,  but  they  may  when  severe  and 
continuous,  indicate  the  severity  of  their  cause. 

They  may  exist  to  a  mild  or  severe  degree  without  infection,  or  rise  of  temperature 
and  be  purely  of  nervous  origin. 

The  more  severe  types  are  usually  confined  to  involvement  of  the  bladder,  ureters 
and  kidneys,  though  they  may  exist  when  the  urethra  alone  is  their  origin. 

Nervous  disturbances  are  of  many  varieties  and  degrees,  as  the  result  of  affections 
within  the  perineum  and  its  associated  organs.  They  may  be  in  the  form  of  local  or 
general  irritability  with  restlessness  and  their  various  associated  phases. 

Cephalalgia  may  exist  with  more  or  less  severity  and  be  localized  or  general,  periodic 
or  constant,  sharp  or  dull,  in  character,  occur  without  infection,  or  the  rise  of  temperature, 
result  from  physiologic  disturbances  alone,  or  any  other  of  the  recognized  causes. 

Delirium  not  infrequently  results  from  the  more  aggravated  conditions  herein  de- 
scribed, and  its  degree  may  not  correspond  with  that  of  infection  or  involvement  of  the 
perineal  structures  and  organs.  It  may  be  mild  or  severe  but  usually  is  of  short  dura- 
tion and  usually  accompanies  a  high  degree  of  temperature  due  to  infection. 

Convulsions  resulting  from  disease  especially  of  the  kidneys  and  uterus,  or  their  ap- 
pendages, are  not  uncommon,  occasionally  due  to  diseases  of  other  parts  of  the  uro- 
genital or  rectal  tracts,  or  the  perineal  body,  and  without  increased  temperature  in  either 
instance.  They  may  be  severe  or  mild,  of  short  or  long  duration  and  of  short  or  long 
intervals. 

Coma  may  follow  immediately  or  soon  after  convulsions,  or  it  may  exist  without  or 
the  previous  occurrence  of  convulsions,  and  vary  from  slight  to  profound  in  degree,  with 
distinct  or  muttering  syllables,  in  the  milder  form,  and  of  short  or  long  duration.  Like 
convulsions  it  follows  the  more  severe  types  of  disease  and  during  their  last  stages. 

Shock  may  be  mild  or  severe,  of  short  or  long  duration,  and  usually  due  to  some 
form  of  trauma,  though  it  may  be  the  result  of  disease.  The  more  severe  forms  are  as- 
sociated with  loss  of  consciousness,  but  such  is  not  the  case  with  that  milder  in  character. 

Page     Twenty-Five 


Because  only  physiologic  symptoms  are  to  be  herein  considered,  it  will  be  necessary 
to  deal  only  with  functional  disturbances,  such  as  pertain  to  the  following  systems : 

1 .  Cardio-vascular.  4.      Urinary. 

2.  Nervous.  5.      Reproductive. 

3.  Lymphatic.  6.      Rectal. 

Conditions  which  cause  symptoms,  are  mentioned  in  each  chapter  and  each  chapter 
intended  to  describe  symptoms  and  their  relation  to  symptoms,  caused  by  conditions  men- 
tioned in  other  chapters,  that  composite  symptoms  may  when  possible  be  definitely  de- 
termined. 

The  study  of  uro-genital  and  rectal  diseases  should  not  be  divorced  and  because 
of  their  very  intimate  relation,  their  consideration  should  represent  but  one  specialty. 

DIAGNOSIS. 

GOULD'S  DEFINITIONS. 

"Diagnosis  is  the  distinguishing,  fixation  or  interpretation  of  a  disease  from  its 
symptoms." 

"Differential  diagnosis  is  the  qualitative  distinguishing  between  two  diseases  of  similar 
character  by  comparative  symptoms." 

"Direct  diagnosis  is  the  recognition  of  a  disease  from  the  existence  of  one  or  more 
signs  or  symptoms,  independently  or  in  relation  with  other  symptoms,  or  with  age,  sex, 
physical  or  mental  characteristics,  residence  or  occupation  or  with  the  family  history. 

"Physical  diagnosis  is  the  application  of  physical  methods  to  the  study  of  disease." 

"Exclusion  diagnosis  is  the  recognition  of  disease  by  excluding  all  other  known  con- 
ditions." 

Certain  diagnoses  may  be  made  exclusive  of  subjective  symptoms,  by  certain  ob- 
servations without  the  use  of  mechanical  devices ;  they  may  often  be  ascertained  by 
what  is  observed  directly  with  or  without  such  means,  but  there  are  many  diagnoses  that 
cannot  be  made  without  the  two  methods  combined  and  still  others  that  can  never  be 
made,  with  all  known  methods  combined,  including  those  objective,  without  mechanical 
devices.      (B.  M.  R.) 

Mechanical  devices  for  diagnosis  have  become  so  perfected  that  they  are  now  in- 
dispensable, for  examination  of  regions  unavailable  to  the  eye  or  sense  of  touch. 

Much  therefore  depends  upon  their  proper  use  in  making  diagnoses  certain.  A 
great  many  times  symptoms  alone  will  be  of  no  avail,  but  now  that  symptoms  have  been 
more  properly  classified  and  understood,  they  will  serve  a  better  purpose  when  me- 
chanical devices  are  resorted  to  for  diagnostic  purposes. 

One  or  more  mechanical  devices  alone  will  frequently  determine  conditions,  but  their 
employment  in  conjunction  with  subjective  or  objective  symptoms  will  be  more  frequently 
necessary. 

Digital.  The  sense  of  touch  and  sight  of  the  examiner  are  the  first  of  the  various 
methods  to  be  applied  in  determining  conditions.  The  first  to  test  sensibility,  tension,  size, 
location  and  shape,  which  when  aided  by  the  second  will  be  more  definite. 

Sounds  may  be  employed  in  detecting  the  course  and  size  of  channels,  their  obstruc- 
tion and  contents,  whether  they  be  in  soft  or  hard  structures,  or  connected  with  normal  or 
abnormal  cavities. 


Sense  of  Sight. 


Eye,  alone.  4.      X-Ray. 

Mechanical.  5.      Microscope. 

1 .  Specula.  6.      Chemical. 

2.  Trocar.  7.      Surgical  exploration. 

3.  Thermometer. 

Page  Twenty-Six 


£];e  alone  may  be  all  sufficient  to  determine  certain  conditions  diagnostically. 

Specula  with  or  without  reflected  light  are  indispensable  many  times  in  canals  and 
cavities,  because  they  bring  to  view  that  which  could  not  otherwise  be  seen. 

The  trocar  permits  of  fluid  being  removed  from  tissues  and  cavities  for  diagnostic 
and  curative  purposes. 

Thermometer.  While  temperature  may  be  determined  by  the  sense  of  touch  and 
general  condition  of  the  body,  its  degree  variance  in  degree  and  location  cannot  be  other- 
wise determined.     It  is  therefore  a  most  important  adjunct  in  diagonstic  measures. 

Radiography  permits  of  shadow  study  in  the  discovery  of  the  presence  of  anomalies, 
disease,  foreign  bodies,  concretions,  and  injuries,  and  has  been  the  most  resourceful  of 
the  newer  methods  in  vogue. 

The  Microscope  for  bacteriological  findings  should  be  employed  with  the  earlier 
examination  and  will  often  decide  the  diagnosis,  without  further  difficulty,  but  its  use  to 
determine  the  character  of  pathology  usually  comes  after  the  completion  of  surgical  work. 

Chemical  analysis  constitutes  the  determination  of  the  constituents  of  normal  and 
abnormal  fluids  and  solids  in  the  body,  whether  they  be  chemical,  microscopical  or  bac- 
teriological. 

Surgical  exploration  should  be  made  at  the  earliest  possible  period  in  the  course  of 
conditions  which  necessitate  a  diagnosis,  or  it  should  be  delayed  until  all  other  methods 
have  been  resorted  to  and  then  completed  if  necessary,  at  the  conclusion  of  the  ex- 
ploration. It  will,  as  a  rule,  be  more  definite  than  all  others,  while  in  some,  all  methods 
combined  will  be  needed  and  a  few  will  then  remain  undetermined. 


Page    Twenty-Seven 


CHAPTER  IV. 


BLOOD  VESSELS. 


ANATOMY. 

N ATOMY  OF  ARTERIES.  As  the  large  and  small  arteries 
are  very  similar,  a  description  of  the  medium-sized  will  suffice. 
An  artery  consists  of  three  main  coats:  1.  The  intima  (or 
inner  layer)  ;  2,  the  media  or  thick  muscular  layer;  3,  the 
adventitia  or  outer  elastic  coat  containing  the  nervi  vasorum, 
vasa  vasorum  and  the  lymph  channels  of  the  vascular  wall. 

Anaiom])  of  the  l^eins.  The  walls  of  the  veins  are  always 
thinner  than  the  corresponding  arteries.  They  are  very  similar  in 
structure,  containing  the  three  coats  somewhat  less  distinctly  dif- 
ferentiated. They  are  more  flaccid  and  less  contractile  in  con- 
sequence of  the  smaller  amount  of  elastic  and  muscular  tissue 
they  contain. 

The  rich  supply  of  blood  to  the  perineum  is  important  be- 
cause of  the  presence  of  so  great  a  variety  of  organs  and  tissues 
and  must  therefore  play   an  important  role  in  symptomatology. 


Fig.   21. — Internal    iliac   artery   and   its   branches    (Deaver). 


Page  Twenty-Eight 


ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 
Anomalies. 
p,..  f     Benign. 

Diseases    |     Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  length,  circumference,  size  of  lumen,  relation  to  other  structures,  or  vessels  en- 
tirely absent. 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Atheromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
varying  in  location,  number,  extent,  partial  or  complete. 

Varicosities  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
involve  several  vessels,  remain  stationary,  continue  to  grow,  or  disappear  spontaneously. 

Aneurisms  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
in  any  vessel  or  locality,  vary  in  size,  remain  quiescent,  continue  to  grow,  or  disappear 
spontaneously. 

Tuberculosis  may  be  primary  or  secondary,  single  or  multiple,  acute  or  chronic,  vary 
in  extent,  location,  remain  quiescent,  continue  to  develop  or  disappear  spontaneously. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  in- 
volve one  or  more  vessels,  disappear,  or  continue  in  its  destruction. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape  and  location. 

Occlusions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
partial  or  complete,  vary  in  location  and  number  of  vessels. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  single  or  multiple,  at  any  point,  in  any 
vessel  or  tissue. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple,  at  any  point,  in  any 
vessel  or  tissue. 

INJURIES. 

Incisions,  ruptures,  punctures,  contusions  are  the  result  of  accident  or  design,  primary 
or  secondary,  single  or  multiple,  longitudinal  or  circumscribed,  vary  in  extent  and  loca- 
tion, through  the  perineal  body,  rectal  or  vaginal  wall,  urethral  canal,  bladder,  or  peri- 
toneal cavity. 

Veins.  Trauma  and  infection,  especially  in  the  female,  are  prolific  in  their  symp- 
tom complex.  Phlebitis  of  the  broad  Hgament  veins,  left  iliac  tributaries,  is  the  most 
common  of  complications. 

The  Pampiniform  plexus  phlebitis  causes  many  obscure  neuroses  and  possibly  neu- 
rasthenias, which  develop  repeated  exacerbations  with  the  slight  uterine  infections  from 
monthly  changes.     D^smenorrhoea  is  usually  associated  with  slight  infections  but  enough 

Page   Twenty-Nine 


to  cause  frequent  phlebltic  involvement  that  subsides  usually  after  a  free  flow  of  blood 
from  the  uterus. 

Hemorrhoidal  vessels  are  frequently  infected,  a  condition  that  may  be  very  serious, 
especially  when  thrombotic. 

Post-operative  infections  of  the  hemorrhoidal  veins  which  are  involved,  intestinal  ulcer- 
ation causing  mesenteric  thrombo-phlebitis  with  gangrene  of  the  intestines  and  appendicitis 
infections,  travel  into  portal  veins  causing  a  portal  thrombo-phlebitis. 

The  uterine  sinuses  in  aborting  and  parturient  women  with  the  associated  clotting, 
may  be  a  prolific  source  of  infection  not  only  of  the  pelvic  veins,  but  also  of  the  general 
peritoneal  cavity,  as  is  manifested  by  the  frequency  of  Coli  cystitis  in  parturient  women. 
Infected  clots  and  decidual  membrane  in  the  puerperal  state  always  cause  some  infection. 
A  perfect  aseptic  lochial  discharge  is  rare  because  change  of  attendants  is  usually  marked 
by  a  temperature  rise  showing  how  very  sensitive  the  parturient  woman  is  to  infection.  This 
is  due  entirely  to  careless  handling  and  lack  of  asepsis. 

SYMPTOMS. 

Symptoms  pertaining  to  blood  vessels  in  the  perineum,  genito-urinary  and  rectal 
tracts,  are  more  or  less  characteristic,  especially  when  the  vessels  have  been  opened  by 
disease  or  injury,  in  which  instance  their  contents  would  escape  into  the  various  soft  struc- 
tures, thereby  producing  the  same  symptoms  that  are  found  with  disease  of  the  lymphatic 
structures,  except  that  pain,  induration  and  tenderness  would  appear  more  suddenly,  there- 
fore more  definitely  determined. 

Anomalies  and  disease  of  vessels  offer  greater  difficulty  in  ascribing  symptoms,  and 
like  atheromatous  degeneration  which  is  usually  due  to  senility,  may  occur  in  middle  life 
with  all  of  the  consequences,  due  to  other  causes.  Arteriosclerosis  may  be  local  or  gen- 
eral, but  when  local,  its  efFects  upon  the  genito-urinary  and  rectal  tracts  are  manifested  by 
certain  symptoms,  such  as  loss  of  function,  atrophy  and  sensation,  each  due  to  loss  of  blood 
supply.  The  same  condition  may  be  the  result  of  congenital  vessel  defect,  but  vessel 
trunks  or  many  of  their  branches  must  be  deficient  to  cause  such  a  condition,  because  of  the 
rich  collateral  blood  supply  within  these  structures. 


Page   Thirty 


CHAPTER  V. 


NERVES. 


ANATOMY. 

^C5^       fS)/\   ^^  ANATOMY  of  the  Nerve    Trunk-     The  fibers  composing 
pj  I  J.         J(  H^  the  peripheral  nervous  system  are  grouped  into  the  larger   and 

N-^^       KaV^>,  smaller  nerve  trunks,  which  extend  to  various  parts  of  the  body. 

In  the  make-up  of  those  that  supply  both  muscles  of  sensory 
surfaces  (integument  or  mucous  membranes)  three  sets  of  fibers 
are  included :  1 .  The  efferent  axones  of  motor  neurones,  whose 
cell  bodies  are  situated  in  the  spinal  cord  or  brain;  2,  the  af- 
ferent dentrites  of  sensory  neurones  withm  the  spinal  and  other 
sensory  gamglia;  and  3,  the  efferent  axones  of  neurones  within 
the  sympathetic  ganglia  that  accompany  the  spinal  fibres  to  the 
periphery  and  serve  for  the  innervation  of  the  involuntary  mus- 
cles of  the  blood  vessels,  and  of  the  skin  and  glands. 

These  fibers  are  grouped  mto  bundles    (funiculi).      Each 
funiculus   is  surrounded  by   a   definite   sheath  of   connective  tis- 
sue,    the     perineum,     which     is     directly     contmuous     with     the 
delicate   fibro-elastic   tissue  prolonged   between   the   individual   nerve   fibers   as   the   endo 
neurium.      (The  perineurium  may  contain  lymph  spaces.)     When,  as  is  usually  the  case, 
the  nerve  is  composed  of  several  funiculi;  these  are  loosely  bound  together  and  the  entire 


Bim^l*.  A^MrffMl   .*B.'.A  . 


Fig.    22. — Diagram    of    the    lumbar    and    sacral    plexuses 
(Deaver) . 

Pag-e   Thirty-One 


Fig.    23. — Diagram    of    sacral    perineum     (Deaver). 

trunk  so  formed  is  invested  by  a  general  envelope,  the  epineurium,  in  which  course  the 
blood-vessels  and  lymphatics.  The  envelopes  of  the  nerve  trunks  are  continued  over  its 
branches  even  into  its  smallest  subdivisions.  The  last  representative  being  seen  on  the 
individual  fibre  as  the  sheath  of  Henle. 

The  perineral  and  sympathetic  nerves,  the  epithelium  of  the  anus  and  the  imme- 
diately adjacent  parts  of  the  rectum  and  the  epithelium  of  the  vagina  and  urethra  are 
formed  from  the  ectoderm,  while  the  urinary  and  generative  organs  except  the  epithelium 
of  the  urinary  bladder  and  urethra  are  from  the  mesoderm.  The  whole  of  the  vascular 
and  lymphatic  systems  and  connective  tissues  are  also  from  the  mesoderm. 

From  the  endoderm  are  to  be  found  the  rectum  and  epithelium  of  the  urinary  bladder. 

The  pudic  nerve  which  supplies  the  perineum,  the  uro-genital  and  rectal  tracts  is  both 
motor  and  sensory,  and  derived  from  the  second,  third  and  fourth  sacral  nerves.  It  was 
split  mto  many  branches  when  the  perineum  was  formed,  which  was  the  beginning  of  the 
mammalian  period. 

One  branch  was  for  the  purpose  of  supplying  the  uro-genital,  the  other  the  rectal 
tract  and  while  the  nerve  has  been  divided  into  two  branches,  their  functions  are  iden- 
tically the  same  and  their  impulses  more  or  less  the  same,  because  the  central  nervous 
system  receives  impulses  from  the  two  alike.  Irritation  of  one,  often  produces  irritation 
of  the  other.  Sometimes  that  of  one  dominates  that  of  the  other  profoundly.  This  is 
often  demonstrated  when  irritation  of  the  sphincter  ani  produces  greater  sexual  excitement 
than  irritation  of  the  sexual  organs  themselves,  and  vice  versa. 

The  pudic  nerve  and  its  branches,  sometimes  vary  slightly  in  their  course,  but  it 
usually  passes  forward  in  the  outer  wall  of  the  ischio-rectal  fossa,  divides  into  the  perineal 
and  dorsalis  penis  nerve  and  accompanies  the  pudic  artery.  Deaver  states  that  nerve 
terminals  like  blood  vessels  and  lymphatics,  are  found  in  each  muscle  fibre,  that  each 
tissue  of  the  body  may  be  brought  under  the  control  of  the  central  nervous  system,  motor 
and  sensory  fibers  being  alike  influenced. 

T op 0 graphically  the  relation  of  the  pudic  nerve,  its  branches,  lymphatic  channels, 
glands  and  blood  vessels,  have  been  materially  changed  to  meet  the  requirements  incident 
to  the  passing  from  the  cloacal  to  the  mammalian  type  of  the  lower  pelvis.     Nerves  travel 

Page   Thirty-Two 


under  the  endothelia,   chiefly  in  bundles,   sometimes  in  net  work  and  all  nerves,  blood 
vessels  and  lymphatics  anastomose  that  they  may  be  more  perfect  in  function. 
Among  the  many  branches  of  the  pudic  nerve  for  consideration  are  the 


1. 

Sacro-coccygeal. 

10. 

Scrotal. 

2. 

Sacral   (posterior  division). 

11. 

Spermatic   ducts. 

3. 

Coccygeal    (posterior) . 

12. 

Uterine. 

4. 

Perineal. 

13. 

Vaginal. 

5. 

Penis-clitoris. 

14. 

Fallopian. 

6. 

Urethral. 

15. 

Ovarian,  each  of  which  is  described 

7. 

Prostatic. 

with  the  tissues  which  they  inhibit, 

8. 

Rectal. 

namely : 

9. 

Testicular. 

1. 

Integument. 

7. 

Glomus  Coccygea. 

2. 

Fascia. 

8. 

Coccyx. 

3. 

Muscles. 

9. 

Cowper's  glands. 

4. 

Organs. 

10. 

Bartholin  glands. 

5. 

Blood  vessels. 

11. 

Rectum. 

6. 

Lymphatics. 

The  multiplicity  of  nerve  trunks  and  fibers  supplying  the  perineal  structures  and 
immediate  associated  organs  and  structures,  must  necessarily  be  the  cause  of  a  great 
variety  of  symptoms. 

Nerve  centers  and  nerve  fibers  are  distributed  in  the  walls  of  all  blood  and  lymph 
vessels,  especially  in  their  deeper  layers  and  are  wound  around  them  by  the  finer  nerves. 
The  adventitia  and  muscularis  contain  two  layers  of  these  small  fibers  which  penetrate  the 
intima. 


Fig.    24. — The    lumbar    plexus    (Deaver). 


Ganglion  cells  are  found  in  the  superficial  layers  of  the  arteries  of  organs,  but  not 
in  their  deeper  layers. 

Page    Thirty-Three 


ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

p^.  f  Benign. 

Diseases  i   a/t  i-         . 
(^  Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape,  length,  course  and  location,  or  be  entirely  absent. 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Neuromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, vary  in  size,  shape,  extent,  location,  remain  quiescent,  or  continue  to  grow,  but 
probably  never  disappear  spontaneously. 

Sy^philis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  vary  in  size,  shape,  location  and  degree,  in  one  or  more  nerves  or  sheaths. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  single  or  multiple,  vary 
in  location  and  degree,  in  any  nerve  or  sheath. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  in  the  sheath  or  body  of  one  or  more  nerves,  contain  blood,  pus  or  serum 
(usually  serum),  vary  in  size,  location,  rate  of  growth,  remain  stationary,  continue  to 
grow,  or  disappear  spontaneously,  without  loss  of  function  when  the  sheath  alone  is 
involved. 

Fistulae  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
remain  open,  close  permanently,  appear  periodically,  open  upon  the  cutaneous  struc- 
tures, into  the  rectum,  vagina,  urethra,  bladder,  uterus  or  peritoneal  cavity. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  single  or  multiple,  in  any  nerve  or  sheath 
(usually  the  sheath). 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple,  in  any  nerve  or  sheath, 
vary  in  size,  location,  rather  of  growth  and  usually  in  the  sheath. 


INJURIES. 

Lacerations,  incisions,  punctures,  may  be  the  result  of  accident  or  design,  primary  or 
secondary,  single  or  multiple,  vary  in  extent,  location,  irregular  in  form,  partial  or  com- 
plete, sharply  defined,  through  the  perineal  body  into  the  urethra,  rectum,  vagina,  bladder 
or  peritoneal  cavity. 

Nerves  are  subject  to  injury  cuid  disease  such  as  inflammation,  acute  and  chronic, 
simple  and  infectious,  therefore  must  necessarily  play  one  of  the  most  important  roles 
in  the  category  of  symptoms  such  as  are  connected  with  the  perineal  body  and  its  intimately 
associated  tissues  and  organs.  The  resistance  of  the  nerves  in  this  region  to  disease,  would 
seem  greater  because  of  the  uro-genital  and  rectal  tracts  possessing  a  greater  variety  and 
number  of  bacteria. 

Page    Thirty-Four 


This  rule  should  obtain  alike  with  blood  vessels  and  lymphatics  which  are  also  the 
distributors  to  muscle,  fat,  fascia,  tendons,  ligaments,  periosteum,  bone,  cutaneous  struc- 
tures and  organs. 

Nerve  sheaths  probably  have  less  resistance,  but  whether  they  can  be  inflamed  to 
any  degree  without  more  or  less  irritation  to  the  nerves  is  uncertain. 

Nerves  like  lymphatics  and  blood  vessels  undergo  degenerative  changes  due  to 
senility,  injury  and  disease.  Then  why  should  such  changes  not  be  earher  in  the  perineal 
region  which  is  inhabited  by  so  many  infectious  bacteria? 

Is  it  not  possible  to  have  such  changes  appear  locally  and  earlier  in  this  region  be- 
cause of  their  presence? 

If  so,  the  manifestations  would  be  atrophy,  resulting  in  pain,  discomfort,  loss  of 
function  or  formation  of  concretions  and  new  growth,  such  as  are  found  to  exist  with 
incontinence,  calculi  and  prostatic  hypertrophy. 

SYMPTOMS. 

Local.  Tenderness  is  elicited  by  the  sense  of  touch  which  may  cause  pain  varying 
in  degree  when  a  nerve  is  injured  or  pathologic.  A  nerve  may  be  sensitive  with  or  without 
pressure  at  the  point  of  lesion  and  though  a  nerve  throughout  its  course  may  be  sensitive 
and  painful  when  its  distal  libers  are  primarily  involved,  the  pain  and  sensitiveness  may  be 
limited  to  such  an  area  or  general  nervous  irritability  may  exist  with  severe  pain,  con- 
stant or  periodic  in  character  throughout  the  pelvis  and  thighs,  especially  the  genito-urinary 
and  rectal  tracts. 

Severe  pain  may  be  associated  with,  or  followed  by  chill,  headache,  shock  and  per- 
spiration. 


Pag-e    Thirty-Five 


CHAPTER  VI. 


LYMPHATICS. 
ANATOMY. 

N ATOMY  of  L^mph-Vesseh.  The  structure  of  the  lymphatics  is 
very  similar  to  that  of  the  veins,  the  largest  ones  having  the 
three  coats,  mtima.  media,  and  adventitia.  The  lymphatics  aris- 
ing from  any  network  come  together  to  form  larger  vessels,  just  as 
do  veins,  but  they  are  more  uniform  in  caliber,  while  a  lymph 
vessel  may  be  the  same  size  as  a  vein  at  its  origin,  it  will  be  much 
smaller  than  the  vein  at  its  termination. 

L))mphatics  are  numerous  and  generally  distributed  through- 
out the  perineal  structures  and  organs,  and  their  function  probably 
more  important  during  the  period  of  gestation. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 
f  Benign. 
\  Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  length,  location  and  number  of  glands  and  channels  or  entirely  absent. 


D 


iseases 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Lymphomala  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, in  suF>erficial  or  deep  structures,  vary  in  size,  shape,  disappear,  remain  quiescent  or 
continue  to  enlarge. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  single  or  multiple, 
vary  in  size,  extent  and  location,  remain  quiescent,  continue  to  grow,  or  disappear  spon- 
taneously. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
single  or  multiple,  vary  in  size,  extent  and  location,  remain  quiescent,  continue  to  grow, 
or  disappear  spontaneously. 

C^sts  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  vary  in  size,  shape  and  location,  contain  blood,  pus  or  serum,  rupture  ex- 
ternally, through  the  perineal  tissues,  internally  into  the  rectum,  vagina,  urethra,  bladder, 
uterus,  or  peritoneal  cavity. 


Page    Thirty-Six 


Fig.  25. — Lymphatics  of  the  blad- 
der in  the  new-born  infant  (Cuneo- 
Marcille). 

a.  External  iliac  gland  (external 
chain).  b.  External  iliac  gland 
(middle  cham).  c.  External  iliac 
gland  (internal  chain),  d.  Deep  in- 
guinal glands.  e.  Left  juxta-aortic 
gland.  /.  Gland  of  the  promontory. 
§.  Lateral  vesical  glands,  h.  Prae- 
vesical   glands. 


Fig.    27. — Lymphatics    of    the    pros- 
tate  (Cuneo  and  Marcille). 


Fig.   26. — Iliopelvic   glands    (Cuneo- 
and   Marcille). 


Fig.  28. — Scheme  of   the   ileo-pelvic 
glands    (Cuneo  and  Marcille). 


MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  single  or  multiple,  in  any  of  the  lym- 
phatic structures  within  the  perineal  body. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple  (usually  single) ,  in  any 
of  the  lymphatic  structures  of  the  perineal  body. 

INJURIES. 

Incisions,  Lacerations,  Contusions,  are  acquired  by  accident  or  design,  primary  or 
secondary,  single  or  multiple,  through  the  perineal  body,  rectum,  or  vagina,  and  vary  in 
degree. 


Pag-e   Thirty-Seven 


SYMPTOMS. 

L})mphatic  duds  and  channels  supplying  the  perineum  subject  to  anomalies,  diseases 
and  injuries,  offer  symptoms  which  are  manifested  by  enlargement,  tenderness,  redness, 
pain,  chill,  temperature,  nausea,  headache  and  vomiting,  and  the  presence  of  serum,  Tblood 
or  pus,  depending  upon  the  degree  of  infection  which  may  be  acute  or  chronic,  primary 
or  secondary. 

Pain  is  not  always  localized  because  it  may  be  reflected  to  adjacent  healthy  tissues 
and  may  also  be  influenced  by  the  degree  of  mfection. 

Induration  is  a  determining  factor  in  the  symptomatology  of  all  structures  even  to 
the  slightest  degree,  but  its  importance  increases  with  degree  especially  in  lymphatic  struc- 
tures. 

Rarely  are  the  lymphatics  of  the  inguinal  or  pelvic  regions  unpalpable.  This  en- 
largement of  the  lymph  nodes  is  associated  with  tenderness  and  pain  which  necessarily 
causes  nervous  exhaustion  and  a  symptom  complex  that  space  to  describe  would  fill 
volumes.  Again  referred  pain  or  reflexes  to  the  knee,  heel  and  back  are  marked.  The 
necessary  combined  intoxication  with  a  slight  febrile  rise  has  frequently  associated  head- 
aches, general  malaise,  loss  of  appetite,  and  a  general  weakness,  all  of  which  causes  in- 
validism. Ulcers  of  the  rectal  wall  may  cause  a  marked  lymphangitis  and  enlarged  lymph 
nodes. 

Vascular  influences  upon  the  lymphatics  are  so  slight  in  the  begmning  that  they  cannot 
be  recognized,  but  as  the  pulse  rate  increases  and  becomes  uniformily  rapid  and  feeble, 
irregular  or  intermittent,  from  any  cause,  the  lymph  ducts  and  glands  may  justly  be  con- 
sidered inactive. 

//  the  temperature  is  high,  lymphatic  involvement  is  at  once  considered,  though  this 
does  not  always  obtain. 

Tenderness  is  one  of  the  first  memifestations  of  glandular  affections,  and  the  degree 
of  pain  increases  with  the  amount  of  involvement  until  it  becomes  a  distinct  characteristic. 

It  may  be  local  or  general,  acute  or  chronic,  without  local  or  general  disturbances, 
color,  infection,  or  induration,  but  these  are  exceptions.  Lymphatic  glands  being  without 
many  sensory  nerve  fibers  must  necessarily  be  without  much  sensation,  and  for  this 
reason  direct  pressure  upon  the  glands  does  not  elicit  much  pain;  it  is  the  surrounding 
structure,  when  involved,  the  nerve  supply  of  which  is  greater,  where  pain  is  produced. 

Normal  glands  are  not  sensitive  to  touch,  but  when  infected,  chill  followed  by 
headache  and  febrile,  disturbances  may  vary  in  degree  and  the  temperature  may  be  local 
or  general.  Headache  may,  however,  result  from  the  slightest  degree  of  infection,  without 
other  symptoms  even  to  the  degree  of  severe  cephalalgia,  but  this  seldom  occurs  without 
the  more  severe  forms  of  infection.  When  they  occur,  nausea  and  vomiting  and  even  shock 
may  be  present  and  vary  in  degree. 


Page   Thirty-Eight 


CHAPTER  VII. 


GLOMUS  COCCYGEA. 
ANATOMY. 

ISTORY. — A  small  reddish-yellow  body  situated  about  the  tip 
of  the  coccyx  was  first  discovered  by  Luschka,  1  859,  since  which 
time  it  has  been  known  as  Luschka's  gland  though  it  has  long 
since  been  discovered  not  to  be  a  gland  because  it  does  not 
possess  glandular  tissue. 

Walker,  1904,  suggested  that  this  small  body  might  be 
a  gland  of  internal  secretion  but  it  can  not  perform  such  a  func- 
tion if  it  does  not  possess  glandular  tissue. 

Much  has  been  written  pertaining  to  the  anatomy,  func- 
tion and  pathology  of  this  most  interesting  mass  of  cells  without 
revealing  anything  definite  concerning  its  physiology.  Until 
such  a  discovery,  continued  interest  will  be  manifested  with  this 
in  view. 

It  is  a  vascular  plexus,  a  rete  mirahele  and  not  a  gland. 
The  human  coccygeal  gland  (so-called)  or  Glomus  coccygea, 
is  a  reduction  product  due  to  the  decrease  in  size  of  the  caudal  region.  In  man  it  usually 
is  found  as  one  ovoid  body  attached  to  the  arteria  sacrahs  media,  lying  on  or  near  the 
ventral  side  of  the  distal  end  of  the  coccyx.  Sometimes  it  is  separated  into  several  pieces 
or  distinct  glomeruli.  It  is  descended  from  the  glomeruli  caudales  of  the  lower  mammals. 
In  the  adult  human  it  is  an  arterio-venous  plexus  of  varying  complexity  and  size. 
The  plexus  takes  the  form  of  a  nodule  inclosed  in  a  fibrous  sheath.  The  vessels  com- 
posing it  may  be  divided  into  the  afferent  artery,  the  efferent  vein  and  the  connecting 
anastomosing  channels.  Although  sparsely  innervated  by  the  sympathetic  it  has  no 
special  relation  thereto.  Besides  the  sheath  and  the  vascular  channels,  the  principal  his- 
tological element  which  forms  a  considerable  part  of  its  mass,  are  the  endotheloid  cells, 
which  are  numerous  and  appear  to  be  derived  from  the  transformed  muscle  cells  of  the 
arterial  walls  and  which  remain  intim.ately  associated  with  the  walls  of  the  vascular 
channels.  Other  than  these,  there  are  no  structural  elements  entering  into  the  make-up 
of  this  organ. 

Non-striated  muscle  cells  are  distributed  throughout  the  stroma. 
It  is  not  known  what  function  the  glomus  serves  in  the  human  physiology. 
Phylogeneticall])  the  human  Glomus  coccygea  is  the  descendant  of  the  numerous 
Glomeruli  caudales  of  the  lower  mammals,  which,  due  to  the  shortening  of  the  tail,  have 
become  condensed  into  the  usually  single  and  much  larger  Glomus  coccygea  of  man. 

The  s})mpathetic  nerve  trunk  accompanying  the  A.  sacralis  media  is  often  enmeshed 
in  the  substance  of  the  glomus,  but  this  is  purely  a  mechanical  relation  as  the  innervation 
of  the  tissues  of  the  glomus  is  not  in  such  cases  increased.  However,  single  and  clusters 
of  "nerve  end"  bodies  somewhat  resembling  Paccinian  bodies,  are  found  in  juxtaposition 
to  the  glomus. 

The  glomus  occurs  as  one  or  man^  nodules  lying  near  the  anterior  aspect  of  the 
tip  of  the  coccyx.  If  often  appears  pedunculate  owing  to  the  elongation  of  the  artery 
and  vein  connecting  it  with  the  median  sacral  vessels. 

Page    Thirty-Nine 


The  glomus  develops  within  a  mass  of  embryonic  cells,  by  the  branching  of  the 
median  artery  and  vein,  and  first  appears  caudad  of  the  actual  tip  of  the  last  coccygeal 

segmen^.  ^^^  ^^^  ^^^  Glomeruli  Caudales  exist  as  a  chain  of  knots  extending  fronvthe  8th 
or  the  9th  caudal  vertebra,  caudad,  to  the  tip  of  the  tail  increasmg  m  size  backward, 
the  largest  glomus  occurring  at  the  tip  of  the  tail.  The  anatomical  and  histological  struc- 
ture is  similar  to  that  of  man.  •      i      -ru 

In  the  Macacus  monkey  as  many  as  ten  glomeruli  occur  in  one  animal.      1  hey  are 
all  closely  attached  to  the  A.  sacralis   (caudalis)    media  and  increase  in  size  from  the 


Fig.   29.— Tail  of  Macacus  Monkey,  showing  a  Glomus  at  each  bony  segment    (Schumacher). 


anterior  caudal  vertebrae  caudad  to  the  tip  of  the  tail.     They  usually  occur  one  in  each 
segment      They  constitute  a  series  of  segmental  plexuses  inserted  between  the  artery  and 
the  vein  and  afford  a  direct  connection  between  the  two  without  the  mediation  of  capil- 
laries.    The  largest  of  them  is  only  a  few  millimeters  in  length. 
Glomerulus  cocc^geus. 

Glomeruli  caudales.  .         r    i  i      i  i  .  l 

Among  mammals  the  glomeruli  occur  in  that  section  of  the  tail  where  the  vertebrae 
lose  their  ventral  arches  but  still  retain  the  haemal  arches. 

Page   Forty 


Glomeruli  have  been  found  in  Beginning  at  the 

Macacus  cynomolgus — common  Macacus. 
Macacus  rhesus 

Felis  catus cat  8th  caudal  vertebra 

Canis  vulpes fox 

Canis  familiaris dog  8th  to  9th  caudal  vertebra 

Lutra  vulgaris otter  1  2th      caudal  vertebra 

Scuirus  vulgaris squirrel  1  0th  caudal   vertebra 

Lepus  canniculus rabbit 

Mus  rattus rat,  mouse      1  4th  caudal   vertebra 

Sus  scropa pig 

Bos  taurus ox 

Equus  caballus horse 

Cynocephalus  hamadryas  Pavin. 


DESCRIPTION  OF   FIGURES. 
S.    V.    Schumacher-GIomus    Coccygea    and    Glomeri    Caudales. 

1.  Section  of  Gl.  coccygeum  of  executed  criminal.     A.,  anastomosing  vessels  with  epitheloid  wall. 
M.,  muscle  bundle  entering  Glomus.     S.,   con.   tissue   stroma.      V.,   outgoing  vein.      X70. 

2.  Closed   anast.   vessel   of   Gl.   c.   of   3-year-old   child.      E.,   endothel    EZ.    epitheloid    cells.      S., 
stroma.      X  460. 

3.  Anast.  vessels  of  Gl.  c.  executed  g  P.  perimysium  internum  inclosing  Epitheloid  cells.     E.  S. 
stroma.      X  460. 

4.  Transition  of  artery  with  anast.  vessel  in  Gl.  c.  new  born  babe.     M.,  nonstriated  muscles  and 
transition  stages   into  epitheloid  cells  eZ.      E.,   endothil    X460. 

5.  Transition   of   anast.  vessels   into  vein   of   Gl.   c.   22-year-old   man,   shows   that   epitheloid   cells 
disappear   as   vein   is   approached    X460. 

6.  Same   as  5   from   5-year-old   child    X460. 

7.  Same  as  5  and  6  from  executed  woman    X460. 

8.  Three  nerve   end  bodies   lying  near  Gl.   c.   lumen   foetus  34   cm.    long.      X460. 

9.  Same  as  8  from  new  born.     L.,  lammellated  bodies.     K.,  capsule.    G.,  location  of  Gl.  c.   X  170. 

10.  Anlage  of  Gl.  c.  human  emb.  52  cm.  long.  A.,  art.  sacralis  media  showing  thickening  of 
media.     M.,  cells  of  media  becoming  epitheloid.     V.,  vein.     E.,  endothel.     X460. 

11.  Section   Gl.   caudale   Cynocephalus  hamadryas.     A.  C.  branch  of   art.    cm.   entering  Gl.  c. 

12.  Artery  of   Gl.  c.  of  dog.      Ac.  wall   of   art  caudalis  media,   showing   muscular   layers.      X70. 

13.  Section  of  anastometic  branch  of  vessel  of  Gl.  c.  of  Cynocephalus  hamadryas.  E.,  endothel. 
I  h.  inner  longit.  muscle.     Z.  M.,  circular  muscle.     A  1.,  outer  long  muscle.     S.,  stroma.    X460. 

14.  Section  anastimolic  vessel  of  dog.     M.,  epitheloid  muscle  cells.     E.,  endothel.     S.,  stroma.    X460. 

15.  Section  anaslomol.  vessel  Gl.  c.  executed  woman.  E.,  endothel.  E  z.  Epitheloid  cells.  S., 
stroma.      X460. 

16.  Two  small  Gl.  c.  55-year-old  woman,  artery  red,  vein  blue,  anastomotic  vessels  violet.      X57. 

17.  Vessels  of  tail  of  Macacus  rhesus  ventral  vein.  A  c  m.,  arteria  caudalis  media.  V  c  m.. 
Vena  caudalis  media.  V  c  1.  Vena  caudalis  media.  A  v..  Anastomotic  veins  between  V 
media   and  V  lateralis.     G.,  Glomeruli  caudales. 

18.  Vessels   from   distal   section   tail   of   Macacus   rhesus.     G.,    large   Glomerulus.     K.,    Small   one. 
1.     J.    H.    Jakobsson.       Glomus   coccygea.      X40.      Sagittal   section   embryo    1.8   cm.    long. 

ar.   arterio   sacralis   media. 

bl.    glomus. 

bp.  vascular  papila. 

c.  central   canal. 

ccg.   glomus  coccygea. 
ch.  chorda  dorsalis. 

d.  gut. 

ep.  epidermis. 

ft.  fllum  terminale. 

kaps.  capsule  of  stroma. 

m.   non-striated   muscle. 

mv.   medullary    tube. 

n.    nerve. 

par.   cartilage  parenchyma. 

str.    stroma. 

su.    caudal    appendage. 

sy.    sympathetic    anlage.  • 

tb.    terminal   vesicle  of  nerve   tube. 

Paae    Forty-One 


-:y 


<;»Q>'b 


>. 


/I 


5^ 


'.^■^.. 


-r-^  ;-^r 


Fig.  30. 


Page   Forty-Two 


,;-.-i>;^ 


f3i«* 


Fig.  31. 


Fig.  32. 


Page  Forty-Three 


■1       \      .*' ' 


Fig.  33. 


Fig.  34. 


Fig.  35. 


Page  Forty-Four 


2.  X20.     Sagittal   section    embryo   7.5    cm.    long 

3.  Xl5.      Sagittal    section    embryo    1.5    cm.    long 

4.  X  15.      Sagittal    section    embryo   6       cm.    long. 

5.  X65.      Transverse  section  embryo  8.1    cm.  long. 

6.  X90.     Section  of  Glomus  coccygea. 

7.  X3(X).   Sagittal    section    of   Glomus    and    med.    tube. 

8.  X300.  Transverse  section  of  Glomus. 

9.  X  55.      Transverse  section  of  Glomus  of  adult. 
10.  X350.  Transverse  section  of  Glomus  of   adult. 


Page   Forty-Five 


Fig.   I. 


Fig-  3 


Fig.  36. 


Page    Forty-Six 


7*i?v 


Fig.  4. 


Fig.  5- 


-56 


Fig.  37. 


Page  Foi-ty-Seven 


Fig-   7- 


^vi^'<u 


V 


Fig.   8. 


^-^i/} 


Fis.  38. 


Page    Forty-Eight 


Fig.  39. 


Page   Forty-Nine 


Anomalies  may  be  in  number  when  several  distinct  bodies  exist  in  the  same  person, 
when  one  is  larger  or  smaller  than  usual,  or  when  it  is  not  situated  immediately  over  and 
in  front  of  the  tip  of  the  coccyx. 

It  may  be  entirely  absent  but  this,  however,  is  only  a  conjecture  based  ilpon  the 
knowledge  that  other  bodies  are  congenitally  absent. 

ETIOLOGY. 

Etiology. — Investigation  pertaining  to  the  function,  pathology  and  symptoms  of  the 
Glomus  is  so  very  meagre,  that  it  is  difficult  to  draw  emy  very  decided  conclusions,  but 
with  the  existence  of  its  irregularities  an  attempt  will  be  made  to  give  it  greater  consid- 
eration in  the  role  of  symptomatology. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 
Benign. 


Diseases 


Malignant. 
Injuries. 


DISEASES. 

Benign,      Malignant. 
BENIGN. 

Benign  diseases  may  be  of  almost  any  variety  and  assume  indefinite  proportions. 
Those  most  common  are  simple  hypertrophy,  lymphoma,  adenoma,  fibroma,  tuberculosis, 
syphilis,  cysts  and  injury,  either  one  of  which  except  tuberculosis  may  be  congenital  or 
acquired. 

Simple  h'^perlroph'^  due  to  some  form  of  infection  may  be  congenital  or  acquired, 
primary  or  secondary,  acute  or  chronic,  vary  in  size  and  location,  undergo  cystic  de- 
generation or  remain  a  solid  growth. 

Lymphomata  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
single  or  multiple,  varying  in  size,  shape  and  location. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  vary  in  extent,  involve 
other  structures,  subside,  continue  to  destruction  or  disappear  spontaneously. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
remain  quiescent,  continue  to  grow,  or  disappear  spontaneously. 

Cysts  quite  frequently  originate  in  the  glomus  and  are  of  several  varieties,  such  as 
echinoccoccal,  dermoid  and  hygroma,  or  they  may  contain  blood,  pus  or  serum,  either 
form  of  which  may  exist  in  the  glomus  primarily  or  secondarily  from  the  articulating  sur- 
faces of  the  bony  segments,  or  the  soft  structures  overlying  the  coccyx. 

Cystic  degeneration  may  also  occur  in  zmy  neoplasms  that  may  affect  the  glomus. 
They  may  be  congenital  or  acquired,  acute  or  chronic,  single  or  multiple,  rupture  into 
and  through  the  posterior  soft  structures,  into  the  rectum,  vagina,  urethra,  bladder,  uterus 
or  peritoneal  cavity. 

Fistulae  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  open  through  the  cutaneous  structures  into  the  rectum,  its  natural  out- 
let, urethra,  bladder,  vagina,  uterus,  perineum  or  peritoneal  cavity. 

Page   Fifty 


MALIGNANT. 

Carcmomata  may  be  primary  or  secondary,  more  often  primary,  because  the  glomus 
is  so  generally  exposed  when  upon  the  tip  of  the  coccyx,  its  normal  position,  where  it 
may  become  irritated  by  the  contents  of  the  rectum,  or  injury  of  any  character. 

Sarcomata  may  be  primary  or  secondary  (usually  primary)  and  at  once  invade 
any  one  or  all  of  the  surrounding  soft  or  bony  structures. 

INJURIES. 

Injuries  to  the  glomus  are  contusions  from  within  and  without  the  rectum  and  many 
times  trans-vagino-rectal  by  the  head  of  the  child  during  delivery,  especially  when  the 
coccyx  is  ankylosed  and  pointing  forward.  This  is  probably  the  most  frequent  source 
of  injury,  though  it  may  be  by  design  or  other  forms  of  trauma. 

SYMPTOMS. 

Being  the  origin  of  many  varieties  of  pathology,  and  because  it  is  so  enriched  with 
nerve  libers  and  highly  sensitized  tissues  immediately  overlying  the  coccyx,  and  because 
of  frequent  pain  and  tenderness  over  the  coccyx,  the  glomus  must  be  considered  symp- 
tomatically. 

It  is  a  preeminent  factor  in  causing  symptoms  associated  with  the  perineum,  coccyx, 
uro-genital  and  rectal  tracts,  and  it  may  be  of  far  greater  importance  than  the  coccyx  in 
the  production  of  pain  or  irritability,  whether  local  or  general,  in  character,  and  intensity 
is  increased  with  the  character  cuid  rate  of  growth. 

A  diseased  or  injured  glomus  should  always  be  suspected  with  the  presence  of  rectal 
pain,  irritation,  or  tenesmus  which  should  be  the  signal  for  a  thorough  examination  of  the 
glomus. 

SURGERY  OF  THE  GLOMUS  COCCYGEA. 

With  the  evidence  at  hand  there  should  be  no  reason  for  doubting  the  propriety  of 
placing  the  glomus  in  the  surgical  category,  even  when  it  is  not  perceptibly  enlarged. 
Especially  would  this  statement  be  reasonable,  if  the  glomus  be  for  internal  secretion. 
Until  a  time  when  its  function  is  discovered,  but  little  attention  will  be  given  to  it  in  any 
way  whatever,  except  so  far  as  it  may  become  involved  with,  or  be  the  origin  of  growths 
serious  in  their  consequences. 

History. — There  is  no  specific  history  pertaining  to  the  surgery  of  the  glomus, 
probably  because  it  has  not  been  dealt  with  in  such  a  manner.  There  is,  however,  an 
occasional  report  of  a  case,  where  neoplasms  of  various  kinds  originating  in  the  glomus, 
have  been  dealt  with  surgically,  and  then  only  when  it  had  assumed  a  considerable  size. 

Indications  for  resorting  to  surgical  measures  when  the  glomus  is  slightly  enlarged, 
are  probably  infection  or  when  it  contains  blood,  pus  or  serum,  or  at  the  beginning  of 
enlargement  due  to  any  cause.  Its  destruction  even  when  normal  should  be  done  when- 
ever the  coccyx  or  any  of  its  associated  tissues  are  removed,  for  any  cause,  especially 
when  done  for  the  cure  or  relief  of  malignant  neoplasms. 

Extirpation  of  the  glomus  alone  may  be  necessary  when  it  becomes  a  source  of 
annoyance  by  hypertrophy,  inflammation  or  degeneration  from  any  cause. 

Technique.— The  removal  of  the  glomus  when  of  ordinary  size  is  best  accomplished 
through  a  posterior  incision  three  inches  in  length,  in  the  median  line  directly  over  the 
lower  end  of  the  coccyx. 

Because  of  the  various  positions  which  it  may  occupy,  number  of  bodies  and  their 
minuteness,  the  removal  of  several  segments  of  the  coccyx  and  the  tissues  immediately 
overlying  them  may  be  necessary  to  eliminate  them. 

Great  care  should  be  exercised  to  avoid  injury  such  as  partial  or  complete  perfora- 
tion of  the  wall  of  the  rectum. 

The  method  of  anesthesia,  dealing  with  the  wound  and  the  after-treatment  is  the 
same  as  that  pertaining  to  coccygectomy. 

Page    Fifty-One 


BIBLIOGRAPHY. 

Luschka,  H.:  Der  Hirnanhang  und  die  Steissdriise  des  Menschen.  Berlin,  1860.  Also,  Die  Steiss- 
druse,  etc.     Leipzig,   1860,  and  de  ranat.  et  Physiol,  etc.,  Paris,  V,  269-271,   1868. 

Arnold,  J.:  Ein  Beitrag  zur  der  sogenannten  Steissdriise.  Virch.  Arch.,  Bd.  32,  1865;  als*}-  Cen- 
talblat.  f.  d.  med.  IVissensch.,  Berlin,  II,  881-883,  1864,  and  Arch.  f.  path,  anat.,  etc.,  Berlin,  XXXII, 
293-331,  I  pi.  1865. 

Senftleben.,  Deutsche  klimk-<    174,    1865. 

Krause,  W. :  Beitrag  zur  Neurologie  der  oberen  Extremitat.,  Leipz.  und  Heidi.,  1865;  also  Ztschr. 
f.  rat.  med.,  1866. 

Krause,  W. :  Uber  die  Glomeruli  caudales  der  Saugetiere.  Virch.  Arch.,  Bd.  39,  1867,  Banks,  Glas- 
gow, M.  J.,  3,  s,  II,  I,  1867. 

Arnold,  Arch.  f.  path,  anat.,  etc.,  Berlin,  XXXIX,  499-512,  2  pi.   1867. 

Macallister,  Brit.  M.  J.,  Lond.,  I,   125,   1868. 

Sertoli,  Arch.f.  path,  anat.,  etc.,  Berlin,  XLII,  370-381,   I,  pi.   1868. 

Sertoli,   E.:      Uber  die  Struktur  der  Steissdiise  des   Menschen.      Virch.  Arch.,   Bd.   42,    1868. 

Macdonald,   Glasgow  M.  J.,  3,  s,   II,    171-73,    1867-68. 

Macdonald:      La  glande  coccygienne  de  I'homme.     jour,  el  VAnat.  el  de  la  Physiol.,  V,  5,    1868. 

Ecker:      Glabella  Coccygea.     Arch.  f.  Anlhropol.     Brschwg.,  XII,    129-155,    1879-80. 

Waldeyer:    Die  Entwicklung  der  Carcione.      Virch.  Arch.,  Bd.  55,    1872. 

Meyer,  G. :   Zur  Anatomie   der  Steissdriise.     Zeitschr.  f.  ral.   med.,  Bd.  28,    1886. 

Hoyer,  H. :  Uber  unmittelbare  Einmundung  kleinsler  Artenen  in  Gefassaste  venosen  Charakters. 
Arch.  f.  mikr.  Anal.,  Bd.   13,   1887. 

Schaffer,  J.:  Zur  Kenntnis  der  glatten  Muskelsellen,  insbesondere  ihrer  Verbindung.  Zeitschr. 
f.  wissensch.  Zool.,  Bd.  66,   1899. 

Jackson:      Upsal.     Lalfaref,  Forh.  N.  F .,  Ill,  324,   1897-98,  mikr.  Anat.   Bd. 

Eberth:      Von   den   Blutegefassen.    Striclfcrs  Ccwebelehre,  I,    1871. 

Von  Ebner,  V.:  Uber  klappenartige  Vorrichlungenn  in  den  .^rterien  der  Schwellkorper.  Anat. 
Anz.  Erganzungsh.  z.,   Bd.,    18,    1900. 

Jakobsson,  H.:  Beitrag  zur  Kenntnis  der  fcetalen  Enl%sicklung  der  Steissdriise.  Arch.  /.  mi'^r.  Anal., 
Bd.  53,  1899. 

Grosser,  O.:  Zur  Anatomie  und  Enlwicklungeschichte  des  Gefass-svstemes  der  Chiropteren.  Anal. 
Helle,  H.  55,  1901. 

Mayer,   S. :    Die   Muscularisierung   der   capillaren    Blutgefaisse.   Anal.   Anz.,    Bd.   21,    1902. 

Mayer,  S.:  Uber  arterio-venose  Anastomosen  an  den  Extremitatenenden  beim  Menschen  and  den 
krallentragenden  Saugetieren.     Arch.  f.  mil^r.  Anal.,  Bd.  60,    1912. 

Vastarini-Cresi,  G.:  Communicazioni  tra  le  arterie  e  le  vene  (anastomosi  artere-venose)  nei 
mammiferi.     Nola  preliminare.  Monit.  zool.  Ilal.,  V,   13,   1902. 

Unger,  E.  und  Baugach,  Th.:  Zur  Kenntnis  der  fovea  and  fistula  sarococcygea  s.  caudalis  und  der 
Ent^vicklung  des  ligamentum  caudale  beim  Menschen.     Arch.  f.  mil^r.  Anat.,  Bd.  61,    1903. 

Unger,  E.  und  Brugach:  Le  anastomosi  arlere-venose  nell  'uomo  e  nei  mammiferi  Studio  anatomo- 
istologico.     Neapel.  Sangiovanni,    1903. 

Von  Hleb-Kosznanska,  Marie:  Peritheliom  der  Luschkeschen  Steissdriise  in  Kindesalter.  Zieglers 
Beilrag,  Bd.  35,  1904. 

Walker,  Thomson:      Uber  die   menschliche  Steissdriise.     Arch.  f.  mi^r.  Anat.,   Bd.  64,    1904 

Von  Schumacher,  S.:  Uber  die  Nerven  des  Schwanzes  der  Saugetiere  und  des  Menschen,  mit 
besonderer  Beriicksichtigung  des  sympathischen  Grenzstranges.  Sitzungsber.  d.  }(.  Al^ad.  d.  IViss,  Wein, 
math-nal.  Kl.    Bd.    114,   Abt.    Ill,    1905. 

Stoerk,  O.:  Uber  die  Chromreaktion  der  Glandula  coccygea  und  die  Bezlehungen  dieser  Driise 
zum  Nervus  sympathicus.     Arch.  f.  mi\r.  Anal.,  Bd.  69,    1906. 

Index  Catalogue  Surg.  Gen'!.  Library,  Vol.  XVIII,  p.  369-370.     Tonsils   (Pharyngeal). 


Page    Fifty-Two 


CHAPTER  VIII. 


THE  COCCYX. 
ANATOMY. 


Fig.  40. 


Pag-e  Fifty-Three 


Glomus    Coccygea. 


Fig.  41. 


THE  many  causes  assigned  lor  diseases  of  the  rectum  and 
prostate  gland,  there  are  perhaps  none  less  frequently  mentioned 
than  deformity  and  diseases  of  the  coccyx.  It  has  been  demon- 
strated in  a  number  of  cases  of  rectal,  prostatic,  bladder  and 
urethral  conditions,  of  a  more  or  less  serious  nature,  that  the 
coccyx  was  directly  or  mdircctly  responsible  for  their  existence, 
because  of  its  close  proximity  to  the  rectal  and  genitourinary 
channels. 

1  he  possibility  of  one  alone  being  affected  must  always 
be  questioned.  A  review  of  their  anatomical  relations,  especially 
those  of  their  nervous  and  lymphatic  structures,  is  essentially  to 
prove  the  truthfulness  of  this  assertion.  While  much  has  been 
said  about  the  coccyx  being  a  causative  factor  in  rectal  symp- 
toms, nothing  has  been  said  about  it  being  the  cause  of  those 
diseases    pertaining    to    the    genito-urinary    system,    or    those    of 


the  genito-urinary  being  the  cause  of  rectal  symptoms. 


(Evolution.) 

Evolutionary  changes  of  the  pelvis  and  its  contents  from  quadrupedal  to  bipedal  have 
not  in  many  instances  been   altogether  perfect,   especially  with  the  caudal  extremity. 

The  coccyx  in  man  is  the  caudal  bony  extremity  composed  normally  of  four  tapering 
segments  extending  do\\Tiward  from  the  sacrum.  Each  joint  is  more  or  less  movable 
and  the  tip  slightly  curved  forward,  vanes  somewhat  in  length  and  diameters,  and  covered 
with  dense  periosteum. 

Cocc^geus  muscle  is  triangular  in  shape  and  supported  externally  by  the  sacro-sciatic 
ligament,  with  which  it  blends.     It  arises  from  the  spine  of  the  ischium,  immediately  above 


Page   Fifty-Four 


Fig.  42. 

the  origin  of  the  levator  ani  muscle,  and  inserted  into  the  side  of  the  coccjoc,  the  lateral 
sacro-coccygeal  ligament  and  the  last  two  sacral  vertebrae. 

Nerve  Supply  is  from  fourth  and  fifth  sacral  and  coccygeal  nerves. 


ligaments  of  th 

le  Pelvic  Floor. 

1. 
2. 
3. 

Anterior  communicating. 
Ilio  Lumbar. 
Anterior  sacro  iliac. 

4. 

Greater  sacro  sciatic. 

5. 
6. 

Lesser  sacro  sciatic. 

Y  Ligament  of  Bigelow^. 

Anterior  communicating  ligament  is  a  wide  band  of  longitudinal  fibers  extending  from 
the  front  of  the  axis  vertebra  to  the  front  of  the  upper  segment  of  the  sacrum  and  grad- 
ually increases  in  width  from  above  downward. 

Ilio  lumbar  ligament  is  a  thickened  lacunia  of  the  fasciae  lumborum  extending  from 
the  tip  of  the  transverse  process  of  the  last  lumbar  vertebra  almost  horizontally  to  the 
inner  lip  of  the  ihac  crest. 

Greater  sacro  sciatic  ligament  is  triangular  in  shape  attached  to  the  posterior  inferia 
spine  of  the  ilium,  besides  being  attached  by  the  first  segment  of  the  coccyx  is  attached 
to  the  third,  fourth  and  fifth  segments  of  the  sacrum  and  inner  side  of  the  ischial  tuber- 
osity below  the  groove  for  the  tendon  of  the  obturator  muscle. 

Lesser  sacro  sciatic  ligament  lies  in  front  under  the  great  sacro  sciatic  ligament 
triangular  in  shape,  attached  to  the  last  two  segments  of  the  sacrum  and  the  first  segment 
of  the  coccyx  and  ischial  spine.  It  is  intimately  associated  with  the  coccygeus  muscle  and 
regarded  as  being  derived  from  it  by  fibrous  transformation  of  the  muscle  fasciculi. 

Ilio  Femoral  or  the  Y  ligament  of  Bigelow  is  a  triangular  set  of  fibers  attached  to  the 
lower  part  of  the  anterior  inferior  iliac  spine  and  the  rim  of  the  acetabulum  and  its  base 
to  the  anterior  intertrochanteric  line  of  the  femur. 


Page   Fifty-Five 


Nerves.  The  posterior  primary  division  of  the  sacral  nerves  with  the  exception  of  that 
of  the  fifth  according  to  Piersol,  emerges  from  the  vertebral  canal  through  the  posterior 
sacral  foramina.  7  he  first,  second  and  third  pass  outward  under  cover  of  the  multifides 
spinae  and  divide  into  external  and  internal  branches,  while  the  external  brcuicttes  unite 
over  the  upper  part  of  the  sacrum  with  a  similar  branch  of  the  fifth  lumbar  and  with  the 
fourth  sacral  nerve,  form  a  series  of  loops  called  the  posterior  sacral  plexus. 

The  posterior  primary  division  of  the  coccygeal  nerve  does  not  divide  into  internal  and 
external  branches,  but  unites  with  the  fourth  and  fifth  sacral  to  form  the  posterior  sacral 
coccygeal  nerves,  the  fibers  of  which  pierce  the  great  sacro  sciatic  ligament  and 
are  given  off  to  be  distributed  to  the  integument  in  the  coccygeal  region,  after 
having  passed  along  the  margin  of  the  coccyx.  It  is  thus  observed  that  these 
nerves  are  involved  with  any  traumatic  or  pathologic  lesions  of  the  coccyx  and  that  any 
such  lesions  should  be  eliminated  before  further  attempt  to  differentiate  any  cause  of  pain 
that  might  be  suspected  or  associated  with  them. 


BIBLIOGRAPHY. 

ANATOMY  OF  COCCYX. 

1 .  Normal. 

2.  Abnormal. 

Analom'^. 

Trefurt,  J.  H.  C.  Ueber  die  Anchylose  des  Steissbeir.s;  deren  Einfluss  auf  die  dadurch  angezeigte 
Kunslhiilfe.     Gottingen,    1836. 

Summers.     Projecting  Coccyx.     Am.  J.  Sc.   Phila.,  ns.  xix,  400,    1850. 

Perrin,  E.     Die  la  glande  coccygienne  et  des  tumeurs  dent  elle  peut  etre  le  siege.     Strasbourg,   1860. 

Krause,  W.     Ztschr.  f.  rat.  Med.,  Leipzig  und   Heidelberg,  3,  R.  293-299,    1861. 

Meyer,  G.     Zlschr.  f.  rai.  Med.,  Leipzig  und  Heidelberg,  3,  R,  xxviii,   135-144,   1   pi.   1866. 

Banks,  W.  M.     Clasgon>  M.  j .,  3,  s,  ii,   1-16,   1    pi.,   1867. 

Sertoli,  E.     Ceniralb.  f.  d.  med.  IVissensch.,  Berlin,  v.  449,   1867. 

Brezzi,  D.     Cicr.  di.  med.  mil.  Firenze,  xv,  3-9,   1867. 

Monod.  Une  piece  anatomique  provenent  d'un  enfant  ne  avec  une  queue.  Bull.  Soc.  d'anthrop., 
Paris,   2,   s,   IV,   407-411,    1869. 

Philipeaux,  J.  M.  Experieces  sur  la  glande  de  croupion  faite  sur  le  canard.  Comp,.  rend.  Soc. 
biol,   Paris,   5,  s,  iv,  49-52.    1874. 

Sayre.      Congenital   Malformation   of   Coccyx,    Operation.      Med.   Rec,    New   York,    ix,   242,    1874. 

Vinogradof,  K.  Malformation  in  the  Region  of  the  Coccyx.  /.  J/pa  normal  i  patrol,  gistologii, 
S.  Petersburg,  x,  506-524,    1876. 

Ecker,  A.  Ueber  gewisse  Ueberbleibsel  embryonaler  Formen  in  der  Steissbeingegend  beim  un- 
geborenen,  neugeborenen  und  erwachsenen  Menschen.  Arch.  f.  Anihrop.,  Braunschweig,  xi,  281-284, 
1878-9. 

Bastian.  Ueber  geschwantzte  Menschen  im  indischen  Archipel.  Verhandl.  d.  Berl.  Cesellsch. 
f.  Anthrop..   BerUn.   412,    1879. 

Bartels,    M.      Arch.   f.    Anthrop.,    Braunschweig,    xiii,    1-41,    1    pi.    1880-81. 

MacDonald,  A.  Backward  Projection  of  Coccyx  with  Anchylosis  of  Sacro-Coccygeal  Joint. 
Edinh.  M.  ].,  xxxi,  318-320,  1885-86. 

Gruber,  W.  Ein  seltener  Curvator  Coccygis  Accessorius  bei  gewissen  Menschen  Homolog  deni 
constanten  Depressor  Candae  Longus  bei  gewissen  Saugethieren  vorher  nicht  gesehen.  Arch.  f.  path. 
Anal,    Berlin,   cix.    1-4,    1887. 

Jacobi,  F.  H.     Arch.  f.  Anal.  u.  EntiDcklngsgesch.,  Leipzig,  353-364,   1888. 

Fry,  H.  D.  The  Function  of  the  Coccyx  in  the  Mechanism  of  Labor.  Am.  J.  Ohst.,  New  York, 
xxi,  1257-1265,  1888. 

Farr,  F.  W.     Case  of  Rigid  Coccyx.     Guy's  Hosp.  Gaz.,  London,  ns,  iii,    173,    1889. 

Torngren,  A.  Ett  fall  af  kongenitalt  coccyxkystom.  Klns^a  lal(  salls}(  handl.,  Helsingsfors,  xxxii, 
388-394,   1    pi.,   1890. 

Fere,  C.  Une  anomalie  du  coccyx  chez  un  epileptique.  A^.  inconog.  de  la  Salpetriere,  Paris,  v. 
89-91,  1  phot.  1892. 

Biancha.  Sulla  interoretazione  morfologica  della  prima  vertebra  coccigea  nell'uomo.  R.  Accad. 
D.  fisioerit.  in  Siena,   Proc-verb,  9,    1895. 

Hlrschberg,  R.     Un  cas  se  mal  perforant  coccygien.     Rev.  neurol,  Paris  xii,  792,   1904. 
Lindquist,  S.     Some  Remarks  on  Obstetrical  Coccyx  Ankylosis. 

Page    Pifty-Six 


Fig.    43. — Posterior     view     of     coccyx     of     Chimpanzee 
(Pat    Roony    the    First,    Cincinnati    Zoo). 

Nord.    Tidsskr.  f.  Terpi,  Kobenh.,  vii,    103,    129,    1908-9. 

Sappy.     On   the  Lymphatic  System.      A  Volume   Frequently   Referred   to  and  Freely  Quoted. 

Hyrtl.      Sitzungsbericht   der   Wiener   Accad.    Moth,    watern.      Kl.    Bd.    liii. 

Rosenberg.      Morphol.  Jahrbuch,   Bd.  L. 


Page  Fifty-Seven 


Fig.    44. — Lateral    View    of     the     Coccyx    of    Chimpanzee     (Pat 
Roony    the    First,    Cincinnati    Zoo). 


ETIOLOGY. 


Anomalies,  Diseases  and  Injuries. 

r  Anomalies. 
Diseases  <    Benign. 

[^  Malignant. 

I    Fractures. 

Injuries     -    Ankylosis. 

f    Luxations. 


Page  Fifty-Eight 


ANOMALIES. 


Anterior    v.ev 


Antfirio  Postener  Curve 
LiUra^l  view 


Personal    Cases   of 
Abnormalities. 
(Ayers    Arrist.) 


Anterior   viev 


tjlrcmi      Antciior    Lutve 


llm  Sei^mciiUd.  Coccyx. 


A-ntcrior   viev 


An   Attcmpl.  J>1    Seimcntalio 


Fig.  45. 

Anomalies  of  the  coccyx  being  of  such  a  diversity,  especially  in  shape,  must  play  a 
certain  role  in  general  symptomology.  Any  variation  from  normal  to  total  absence  must 
be  determined  before  considering  the  subject  in  a  general  way.  This  may  be  done  by 
palpation  with  the  finger  except  in  a  few  instances  where  segments  are  wanting,  then  it  is 
difficult  to  define  the  hmitations  of  the  lower  portion  of  the  sacrum.  The  sacrococcygeal 
line  may  never  be  determined  with  the  existence  of  such  a  condition. 


Congenital  def 

ects  of  the  coccyx 

1. 

Length. 

2. 

Diameter. 

Shape. 

4. 

Flexibility. 

D. 

Ankylosis. 

6. 

Absence. 

Paee    Fifty-Nine 


Length  may  vary  from  long  to  short.  When  long  it  may  be  due  to  increased  length 
of  the  segments  or  sacrum,  or  both.  Sometimes  though  infrequent,  the  segments  may  be 
increased  to  six  or  more  in  number. 

Excessive  length  more  frequently  causes  inconveniences  than  excessive  shorteess,  which 
is  due  to  the  segments  being  diminished  in  length  or  number. 

Diameters  of  the  segments  of  the  coccyx  vary  considerably  from  large  to  small. 
Any  one  or  all  may  be  excessive  in  the  lateral  or  anterior-posterior  measurements. 

Shape  may  be  regular  or  irregular,  smooth  or  rough,  sharp  or  blunt  on  the  edges, 
or  at  the  point. 

Flexibility  varies  in  degree  and  direction.  It  may  be  unilateral,  bilateral,  anterior, 
posterior  or  movable  in  all  directions,  and  occasionally  displaced  downward  by  traction, 
a  type  referred  to  as  floating  coccyx. 

Ankylosis  may  be  partial  or  complete,  straight,  angular  or  curved  laterally,  anterior 
or  posteriorly. 

Absence.  Several  instances  have  been  cited  where  the  coccyx  was  congenitally 
Wcuiting  in  part  or  its  entirety,  thus  indicating  that  it  is  on  the  road  to  disappearance  and 
that  it  is  not  an  anatomic  or  physiologic  necessity. 

Anomalies. 

Post.      Ne-w    York    M.    /..    xxx,    517,    1879. 
Imlach.     Brh.  Gpnec.  /.,  London,  i,  319,   1885. 
Whitehead.      Lancet,    London,    ii,    I  12,    1886. 
Odell.      Lancet,    London,    1088,    1887. 
Evans.     Phila.  Med.   Times,  xviii,  35,    1887-88. 
Dunn.      Cu^'s   Hosp.   Rep.,    London,    xxx,    191,    1889. 
Darrach.      Boston   M.    &   S.   J.,    xxviii,    36,    1893. 


DISEASES. 

Benign.      Malignant. 

Neoplasms  niop  be  congenital  or  acquired,  of  many  kinds  and  varieties,  primary  or 
secondary,  vary  in  size,  shape,  number  cind  location,  develop  in  any  direction,  involve  by 
extension  any  of  the  soft  or  bony  structures  of  the  lower  pelvis  and  perineum. 

History. 

Zeddler,  1 834,  reported  a  case  of  steatoma  of  the  coccyx,  the  first  of  its  kind 
to  be  recorded. 

Heschel,  1  860,  reported  simple  hypertrophy,  and  Clemantais,  1  883,  one  of  simple 
growth  with  fistulae.  Erass,  1883,  a  congenital  tumor,  Jewett,  1884,  an  angioma. 
Barber,  1910,  a  tumor  in  the  coccygeal  region  of  an  infant  six  months  old,  and  Bod,  1910, 
a  ccLse  of  hernia  of  the  spinal  cord  in  the  coccygeal  region  operated  upon  by  Zenenk's 
method. 

BENIGN. 

Benign  diseases  of  the  coccyx  may  be  congenital  or  acquired,  primary  or  secondary, 
acute  or  chronic,  remain  small  or  assume  a  considerable  size,  of  many  varieties,  and  asso- 
ciated with  angioma  of  the  spinal  cord  and  various  other  types  of  new  growth  to  com- 
plicate their  differentiation. 

Coccygitis  may  be  the  result  of  injury  or  disease  of  the  coccyx,  tissues  overlying 
or  indirectly  associated  with  the  coccyx. 

Chondromata  may  be  congenital  or  acquired,  primary  or  secondary,  single,  vary  in 
size,  shape,  location,  usually  in  the  lower  segments,  slow  or  rapid  in  growth,  remain 
quiescent,  increase  in  size  or  disappear  spontaneously,  though  this  seldom  occurs. 

Osteomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
originate  in  any  one  or  more  of  the  segments  or  their  periosteum  and  vary  in  size.      The 

Page   Sixty 


secondary  growths  extend  from  the  sacrum  and  the  primary  growth  of  the  coccyx  may 
in  turn  become  secondary  in  the  sacrum. 

Degeneration  of  one  or  all  segments  of  the  coccyx  may  be  in  the  form  of  caries  or 
necrosis  due  to  tuberculosis  (Caubet)  syphilis,  osteomolitis  (Monnier)  or  injury.  Kuss, 
1909,  reports  a  case  of  retro-anal  fistula  due  to  tuberculosis  of  the  segments  of  the  coccyx. 
Such  degeneration  may  be  secondary  to  disease  of  the  sacrum  or  the  soft  tissues  im- 
mediately surrounding  the  coccyx. 

Tubercular  degeneration  may  be  acute  or  chronic,  mvolve  one  or  more  segments, 
primary  or  secondary  rupture  into  the  rectal  cavity,  externally  through  the  cutaneous  struc- 
tures, or  extend  into  the  sacrum  and  rupture  in  any  direction. 

Syphilitic  degeneration  may  be  congenital  or  acquired,  primary  or  secondary,  acute 
or  chronic,  occasionally  destroy  the  coccyx  without  manifestations  elsewhere,  or  the  over- 
lying soft  structures  posteriorly,  laterally  or  anteriorly  into  the  rectal  cavity. 

Osteomyelitic  degeneration  rarely  occurs  in  the  coccyx,  but  when  it  does  occur,  it 
is  subject  to  the  same  rules  concerning  the  destruction  of  its  overlying  soft  structures. 
It,  too,  may  be  primary  or  secondary  to  the  sacrum,  which  it  usually  involves  when  primary. 

Etiology. 

Cummenus,   A.  H.     Misc.  Acad.  net.  curios,   1672,   Lips,   el  Francof,   iii,    1672,   209. 

Faye,   F.  C.     Norsk-  Mag.  f.  Laegevidensk,   Christiana,    ii,    591-593,    1848. 

Boyer,  L.     Rev.  med.  chir.,  Paris,  xi,  246,    1852. 

Cleaveland,   C.   H.     New  Jersey   M.  Reporter,   Burlington,  vi,    171-1853. 

Hersher,  D.  W.     Boston  M.  &  S.  /.,  liv,  516,   1856. 

Roeser.  Luxalio  ossis  coccygis.  Memorabillien,  Beilbr.  1856,  i,  No.  18,  1,  also  (Abstr.)  Noliz. 
f.  prakl.  Aerzte,  etc.,  Berlin,  1858,  n,  F.  i,  415,  also  Trans.  Brit.  &  For.  M.  Chir.  R.,  London,  xx, 
544,  1857. 

Uhde,  C.  W.  F.     Fraclura.  Deutsche  Klinik,  Berlin,  ix,    108,   1857. 

Bonnefont.      Luxation.       Union    Med.,    Paris,    2,    s,    i.     136-138,    1859. 

Mouret.      Rec.   de.   mem.   de.   med.   mil.,   3,   s,   i,   350-376,    1859. 

Faye,    F.  C.     Norsk  J^og.  f.  Laegevidensk,   Christiana,   xv,    137-146,    1861. 

Barrt  de  la  Faille,  J.     Nederl.  Tijdschr.  v.  Heel-en  Verlosk,  Utrecht,  xxi,  537-541,   1861-2. 

Sky,  Lancet,  London,  ii,  326,    1861. 

Belts.      Memorabil.,   Heiibronn,   x,   58,    1865. 

Warren,  J.  M.     Injuries.     In  his  Surg.  Obs.,  Boston,  593-597,    1867. 

Macdonald,  W.     Glasgow  M.  /.,  3,  s,  li,    171-173,    1867-8. 

Denuce,  P.  Des  fistules  ossifluentes  de  la  region  anale.  De  la  resection  du  coccyx  et  des  ses 
indications,    Paris,    1874. 

Bellamy,  W.  J.  H.     Nort.  Car.  M.  /.,  Wilmington,   1,   151,   1878. 

Blockwood.     Proc.  Phila.  Med.   Soc,   ii,   56,    1880. 

Couraud,  J.  Contribution  a  I'etude  des  depressions  fistules  congenitales  cutanees  et  kystes  dermoids 
de    la    region   sacrococcygienne,    Paris,    1883. 

JoUv,  W.  J.     Med.  Rec,  New  York,  xxxii,  762,    1887. 

Baiiey,  W.  W.  J.     Med.  Soc,  A.kansas,  Little  Rock,  iv,   108,   1893-4. 

Jackson,   Pausdale.     Lancet,  London,   i,   209,    1896. 

Le    Ray.      Echo    Med.,    Toulouse,    2,    s,    x,    61,    1896. 

Dieulafe  and  Giles.      Toulouse  Med.,  2,   s,  v,   248-250,    1903. 

Necrosis. 

Shidsgaard  Hosp.      Tid.  Kjobenh.,  vi,    121,    1863. 

Braune,  W.     Monaischr.  f.  Cehurtsk.  u.  Frauenkr.,  Berlin,  xxiv,   1-10,    1    pi,    1864. 

Dunn,   L.   A.      Guys  Hosp.  Rep.,  London,  3,  s,  xxxi,    191-196,    1889. 

Darrah,  R.  E.  A.     Boston  M.  &  S.  /.,  cxxviii,  36-38,   1893. 

Raymond,   F.   N.      Iconog.   de   la  Salpetriere,    Paris,   viii,   65-106,    1    pi.,    1895. 

Monmer,  L.     Rev.  d'orthrop..   Pans,   xxx,   201-396,    1904,   xxxi,   643,    1905. 

Villemin,    P.      Tubercul.    inf.,    Paris,    ix,    97-100,    1906. 

Marro,    G.      Arch,   di    pschiat.    Torino,    xxviii,    445-454,    1    pi.,    1907. 

Kuss,   G.      Bull,    el   mem.   soc.   anal.,    Paris,   Ixxxiv,    645,    1909. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple.  When  primary  they  originate  from  the  articulating  surfaces  of  the  long 
segments,  while  those  secondary  may  originate  from  the  sacrum  or  the  soft  structures  sur- 
rounding the  coccyx.  They  may  be  tubercular,  syphihtic,  dermoid  or  hydatid,  and  con- 
tain serum,  blood,  pus,  echinococci,  or  epithelial  structures  such  as  hair,  teeth  and  some- 
Page    Sixty-One 


times  bone  known  as  teratoma  or  dermoid.  Either  of  these  forms  may  be  congenital  and 
all  with  the  exception  of  the  dermoid  variety  may  be  acquired. 

Cysts  may  result  from  degeneration  of  osteomata  or  other  benign  or  malignant  neo- 
plasms.    Indeed,  these  are  quite  frequently  their  origin. 

They  may  rupture  externally,  into  the  vagina,  uterus,  urethra,  bladder,  peritoneal 
or  rectal  cavity,  usually  into  the  rectum,  remain  open  indefinitely  to  close  spontaneously, 
or  continue  to  form  a  permanent  fistulous  tract. 

History. 

Fistulae  have  been  reported  by  Macdonald,  1867,  Denuce,  1874,  Couraud,  1883, 
and  Jolly,  1887,  the  last  named  having  seen  a  case  in  which  the  coccyx  passed  per  anum, 
after  having  been  subjected  to  fracture.  Gehrung,  I  888,  reported  a  case  of  dislocation  of 
the  coccyx  and  Bailey,  1  893,  one  of  fracture  in  \vhich  an  incorrect  diagnosis  was  made. 
Le  Roy,  1  896,  one  of  coccygeal  fistula,  and  GiUes,  1  903,  of  retro-expulsion  of  the  coccyx. 

Sinuses  in  the  overlying  soft  structures  almost  invariably  result  from  any  injury 
or  disease  of  the  coccyx. 

Fistulae  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  connect  any  part  of  the  uro-genital,  peritoneal  or  rectal  tracts  or  coccyx, 
their  strutcures,  or  the  structures  of  the  perineum. 

The  fluids  passing  through  these  fistulous  tracts  may  be  fecal,  urinary,  seminal, 
peritoneal,  blood,  pus  or  serum,  from  the  uterine  cavity,  any  bony  tissue  about  or  near 
the  pelvis,  or  from  a  lesion  within  the  soft  structures  of  the  perineum  independently. 

MALIGNANT. 
Sarcomata.     Carcinomata. 

Malignant  Neoplasms  of  the  coccyx  aie  numerous  in  variety  and  probably  grow  as 
rapidly  as  when  other  tissues  or  organs  are  similarly  affected. 

History. 

Heretaux,  1882,  reported  a  case  of  sarcoma  of  the  coccyx  and  Raingeard,  1884, 
observed  a  case  of  sarcoma  originating  at  the  sacro-coccygeal  junction  with  complete 
degeneration  of  the  coccyx. 

Many  such  cases  have  been  observed  before  and  since  the  time  of  these  reports. 

Sarcomata  may  occur  in  many  varieties,  develop  slowly  or  rapidly  and  become  of 
considerable  sizes.  They  may  be  primary  or  secondary,  involve  the  sacrum  or  secondary 
to  the  sacrum,  originate  in  the  segments,  their  synovial  linings,  periostial  or  other  soft 
tissue  coverings  and  in  the  form  of  teratomata. 

Carcmomata  are  probably  of  rare  occurrence  in  the  coccyx  but  as  its  overlying  soft 
structures  are  frequently  its  origin  it  is  necessary  to  consider  it  especially  in  secondary 
involvement.     1  hey  may  be  primary  or  secondary,  vary  in  size,  shap)e  and  location. 

Neoplasms. 

Zedler.      Cen.  San.  Ber.  v.  Schlesien,  fur  das  Jahr.      1832,  Breslau.  334,    1834. 
Lepellepetries.     Lancet,  London,  4-11,    158,    1883. 
Stanley.     Med.-Chir.    Trans.,   London,   xxiv,    1841. 
Chibb.      Med.    Times,   London,  xvi,  274,    1874. 
Johnson.     Lancet,  London,  ii,  35,    1847. 

Herschl,  I.     Oesterr.  Ztschr.  f.  prakl.  Heilk..  Wien,  vi,  221-224,   1860. 

Baune.      Das  Doppelbild   und   Geschw.   d.   Krenzbein   Geg.,    Leipzig,    1862,   Ang.    Steissbeingeschen. 
Monatschrift  filr  Ceburishilfe  und  Frauen}(ran}(heiten,  xxiv,    1864. 
Ellis.    Boston  M.  &  S.  J.,  ixxii,  417,  1865. 

Buck.     Coccyx  Cysts.     l\.  Y.  Med.  Record,  96,   1866. 

Holmes.     Brit.  M.  J.,  London,  315,    1867. 

Mason.      Trans.   Path.    Sac,   London,    xxv,    194,    1874-5. 

Cabot.     Sacral   Teratom.     Boston  M.  &  S.  J.,  xcviii,    112,    1878. 

De   Rothschild.     Bull.   Soc.   d'obst.,   Paris,  ii,    112,    1878. 

Shattuck.      Trans.  Path.  Soc,   London,  xxiv,    197,    1880-1. 

McDowell.      Med.  Press   &   CiVc,  London,   xxxiii,   271,    1882. 

Hertaux,     /.   de   Vouesl.  Nantes,   xvi,   377,    1882. 

Paae    Sixtv-Two 


Chenantais.     /.  de  med.  de  I'ouesl,  N antes,  xvii,  457,    1883. 

Eross,  G.     Orvosi  helil,  Budapest,  xxxix,  973-979,   1883. 

Jewetf,  F.  A.   N.     A^en;    York  M.  /.,  xxxix.   612,    1884. 

Raingaard.     /.  de  Med.  de  I'ouesl,  Nantes,  xviii,  281-284,    1884. 

Favel  &  Jackson,  Lancet,  London,  i,  843,   1885. 

Leriche.     Cong,  franc,  de.  chir.,  proc-verb.,    1886,   Paris   ii,   519-525,    1887. 

Owen.      Trans.   Path.   Soc,   London,   xxxi,   425-7,    1887-8. 

McCarthy.     Lancet,   London,   i,  920,    1888. 

Bowlby.      Coccygeal   Tumors.      Brit.   M.   J.,   London,   i,   663,    1890. 

Vincent,  E.     Mem.  el  compl.  rend.  soc.  d.  sc.  med.  de  Lyon,    (18S9)    xxix,  pt.  2,    180-182,   1890. 

Borst.     Die  angie  Geschwulst  der  sacr.  Region.     Centralb.  f.  Allg.  path.  u.  path.,  Jena,  ix,  449,  1896. 

Jahr.  d.  Basn.  Herzegovina,  landespil  in  Sarjeno,   1894-96,  787-90,  Wien,    1898. 

Alezais-Peyron.      Compl.  rend.  Soc.  de.   Biol,   Paris   Ixvi,    1121,    1909. 

Barbarin,  P.     Paris  Chirurg.,  ii,  229-231,    1910. 

Brod,    I.   S.     Khirurgia.  Mosff.,   xxviii,   31-33,    1910. 

INJURIES. 
Fractures. 

Injuries  of  this  character  in  the  male  are  usually  caused  by  direct  force  applied  from 
below  or  behind,  while  in  the  female,  the  pressure  from  the  foetal  head  during  delivery  is 
an  added  cause. 

History. 

Fractures  of  the  coccyx  have  been  of  many  varieties  and  due  to  many  causes. 
Cummenus,  1672,  reported  on  its  luxations,  Faye,  1848,  fracture,  Boyer,  1852,  fracture 
with  reduction,  and  Cleaveland,  1853.  on  fracture  due  to  difficult  labor.  Herschey, 
1856,  observed  a  case  of  simple  exfoliation  of  the  coccyx,  Mouret,  1859,  an  incomplete 
luxation,  Faye,  1861,  one  of  fracture  resulting  in  ankylosis,  and  Bellamy,  1878,  one  of 
gunshot  wound  of  the  coccyx  and  perforation  of  the  rectum. 

Fractures  of  the  coccyx  are  due  to  injury  or  disease,  and  are  classed  as  acquired 
causes.  They  too  will  produce  sjanptoms  which  are  associated  with  the  uro-genital  and 
rectal  tracts 


tractures. 

a. 

Simple. 

b. 

Compound. 

c. 

Comminuted. 

d. 

Compound  comminuted. ' 

Simple  fractures  may  occur  in  one  or  more  segments,  transverse,  oblique,  lateral  or 
perpendicular,  or  they  may  be  associated  with  fractures  of  the  sacrum. 

Simple  fractures  of  the  coccyx  may  be  associated  with  a  simple  fracture  of  the  sacrum, 
such  a  case  having  been  observed  in  a  woman  38  years  of  age  as  the  result  of  a  fall, 
the  force  of  which  was  directed  perpendicularly  through  the  sacrum  from  below.  This 
is  the  only  case  found  recorded.  The  fracture  apparently  was  transverse  through  the 
sacrum,  while  that  of  the  coccyx  was  transverse  through  the  articulating  surfaces  of  the 
third  and  fourth  segments.  The  pain  resulting  from  the  fracture  was  excruciating  and 
only  relieved  by  excision  of  the  coccyx  by  local  anesthesia.  The  pain  and  tenderness, 
however,   continued   for  several   months  thereafter  in  the  region  of  the  sacral   fracture. 

Compound  fractures  may  occur  in  one  or  more  segments,  even  to  being  associated 
with  that  of  the  sacrum,  and  the  laceration  of  soft  tissue,  extend  laterally,  posteriorly  through 
the  cutaneous  structures,  or  anteriorly  through  the  wall  of  the  rectum. 

Comminuted  Fractures  may  involve  one  or  more  segments  alone  or  be  associated  with 
that  of  the  sacrum. 

Compound  Comminuted  Fractures  may  occur  in  one  or  more  segments  alone,  or 
with  that  of  the  sacrum  and  involve  the  soft  structures  laterally,  posteriorly,  or  anteriorly 
through  the  wall  of  the  rectum. 

Either  of  the  foregoing  fractures  may   result  in  infection,   and  abscess  which   may 

Pag-e  Sixty-Three 


rupture  into  the  bladder,  uterine  or  peritoneal  cavity,  the  vagina  or  rectum,  which  is  the 
most  common  course. 

Ank})losis  may  be  of  any  degree  from  slight  movement  to  complete  mobility,  and 
in  many  positions  from  straight  to  curve,  or  angular,  laterally,   emteriorly  or  posteriorly. 

Flexibility  is  more  frequent  in  the  female  and  ankylosis  in  the  male.  The  latter 
probably  being  due  to  hardship  and  a  smaller  pelvis.  Ankylosis  is  also  produced  by 
prolonged  sitting  posture. 

Luxations  may  occur  in  one  or  all  joints,  even  to  complete  separation  from  the 
coccyx,  anteriorly,  posteriorly  or  laterally,  and  such  conditions  are  very  much  inclined  to 
cause  considerable  irritation  and  pain.     Their  degree  being  influenced  by  occupation. 

SYMPTOMS. 

{Coccyalgia. 
Coccygalgia. 
Coccygodynia. 

The  coccyx  having  not  escaped  the  influences  wrought  by  the  anatomical  changes 
in  the  perineum,  should  be  considered  an  important  factor  in  the  causation  of  symp- 
toms and  surgical  conditions,  which  are  many  times  extremely  complex  in  character  and 
their  relation  to  the  rectal  and  uro-genital  systems. 

Sensory  impulses  pass  upward,  motor  impulses  downward,  indicating  that  the  coccyx 
plays  the  role  of  a  disturber  more  than  that  of  the  disturbed.  It  is  an  offender,  not 
defender,  therefore  must  be  the  cause  of  complex  symptoms  especially  because  of  its 
relations,  attachments  and  exposed  position. 

The  congenital  or  acquired  absence  of  the  coccyx  does  not  interfere  in  the  least 
with  the  function  of  muscular  fibers  which  are  attached  to  it  normally. 

The  periosteum  enveloping  the  coccyx  may  be  primarily  or  secondarily  affected  by 
disease  or  injury  or  their  consequences  and  for  this  reason  must  be  considered  independently 
in  the  causation  of  symptoms,  though  it  may  not  have  received  proper  recognition. 

History. 

Pain  neuralgic  in  character,  in  the  coccyx,  has  been  recognized  for  many  years 
but  little  was  written  about  it  until  after  Nott,  1 844,  of  New  Orleans,  delivered  an 
address  upon  the  subject.  Since  then  much  has  been  said  about  the  coccyx  being  a  causa- 
tive factor. 

Scanzoni,  1861,  Jenks,  1873,  Worms,  1876,  and  Rockwell,  1877,  each  reported 
a  case  of  pain  due  to  injury.     Hale,   1  888,  also  had  one  due  to  disease  of  the  segments. 

Goodall,  1883,  Sutton,  1888,  Montgomery,  1895,  Fletcher,  1897,  and  Courtois- 
Suffit,   1  904,  and  1910,  reported  coccygodynia  of  traumatic  origin. 

Many  others  have  contributed  most  excellently  to  the  sum  total  of  our  knowledge 
of  this  subject. 

Pain  and  tenderness  are  probably  the  most  common  symptoms  and  they  may  be 
due  to  many  causes  direct  or  indirect,  primary  or  secondary,  such  as  injury  or  disease 
of  the  coccyx  or  nerves  associated  with  it.  It  may  be  mild  or  severe,  acute  or  chronic, 
constant  or  periodic,  and  appear  at  any  age,  in  either  sex,  but  more  frequent  in  the  female 
before  fifty  years  of  age.  It  is  rare  in  the  very  young  and  old,  and  any  degree  of  pain 
may  exist  with  or  without  infection  of  any  character  or  degree  and  when  a  deformed 
coccyx  pulls  on  muscular  fibers  that  are  out  of  their  normal  position. 

The  coccyx  when  diseased  or  deformed  quite  frequently  produces  irritation  of  the 
rectal  and  urinary  system  in  part  or  in  general,  and  frequent  urination  and  defecation  as- 
sociated with  or  without  pain  or  tenesmus  and  general  nervousness  are  quite  commonly 
associated  with  its  abnormal  conditions.  Tenderness  is  usually  pre-ent  with  all  and  any 
irritation  resulting  from  such  a  condition  may  result  in  infection  and  abscess  with  all  of 
their  sequellae  at  any  point  within  the  genito-urinary  or  rectal  tracts. 

Page   Sixty-Pour 


Rcclal  or  uro-gcnital  pathology  of  any  kind  or  degree  may  produce  coccyalgia  vary- 
ing in  severity  and  resuil  in  general  or  sexual  neurasthenia,  especially  when  severe  in  either 
the  acute  or  chronic  form. 

COCCYALGIA. 

Bibliography. 

Coccyalgia. 

Nott.     Aem  Oilcans  M.  /..  i,   1844. 

von  Scanzoni,  F.  W.     Ueber  coccygodyn.      IVurzburg  mcd.  Zbcbr.,  820,    1861. 

von    Scanzoni.      Ueber    coccydynie,   Wiirzburg,    1861. 

Gosselin.      Coccyodynie.      Caz.  J.  hop.,   Paris,   xxxiv,  489,    1861. 

Faye,   F.  C.     Coccyodynie  Resulting   from  Fracture.      Norsf;.  Mag.  f.  Laegc\>idensk<  Christiana,  xv, 

137-146.   1861. 

von    Frangui.      Ueber    Coccygodynie.      McmoTabilien,    Heidelberg,    viii,    109,    1862. 

von   Scanzoni.      Memorabilien,    Heilbronn,  vii,   40,    1862. 

von   Franque,   A.      Memorjbilien,    Heilbionn,   vii,    105-107,    1863. 

Am.    I.   ObsL,   New   York.  243,    1869. 

Coccyigodinia.  Barth.  Malta.,  i-iii,  213-219,    1871-5. 

Jenks.   E.  W.      Tr.  M.  Soc,  Michigan,  Lansing,  vi,    118-128,    1873. 

O'Reilly.   J.      Am.  PracL,   Louisville,   ix.   327-334,    1874. 

Worms,  J.     Did.  Encyclop.   d.  sc.   med.,   Paris,   xviii,    174-179,    1876. 

Jenks,    E.   W.      Med.  Rec,    New   York,   xvii.   417-421,    1880. 

Goodell,    W.      Clin.   News,    Philadelphia,    i,    219,    1880. 

.Aschenborn,   O.     Arch.  f.  k^in.   Chir.,   Berlin,   xxv,    174,    1880. 

Laub,  H.      Cynael.  eg.  obsl.  Medd.,  Kjobenhagen,   3,  R.  iii,   29-37,    1881. 

Woodward,  A.  T.     Med.  &  Surg.  Reporter,  Philadelphia,  xlv,   398.    1881. 

Goodell.     W.     Phila.  M.    Times,  xiv.   756-758,    1883-4. 

Madelung,  O.     Cenlralh.  f.  Chir.,  Leipzig,  xii.   761-764,    1885. 

Ferouson.  A.  H.     Canad.  Pracl.   Toronto,  xi,  233-235,    1886. 

Morion,  A.  E.     Med.  Reg.,  Philadelphia,  iv,   126,   1888. 

Hale,   E.   M.      Homeop.  ].   Obsl.,   New  York,  x,  9-26,    1888. 

Grafe,  M.  Ein  Beitrag  zur  Astiologie  and  Therapie  der  Coccygodynie.  Ztschr.  f.  Ceburlsh.  u. 
Cynak;  Stuttgart,  xv.  344-353.  1888. 

Sutton,  R.  S.  A  new  and  reliable  remedy  for  coccygodynia  and  puntis  am.  Med.  &  Surg. 
Reporter,    Philadelphia,   Ixiii.   563.    1888. 

Kuezora.    W.      Ueber   Coccygodynie  und    ihre    Behandlungsweise.      Wiirzburg,    1888. 

Peyer.  A.     Centralb.  f.  Klin,  med.,  Leipzie,  ix,  657-662.   1888. 

Cooper.  H.   P.     Atlanta  M.  &  S.  J.,  ns,  vii.   1-10,    1890-91. 

Carriere.      La   sacro-coccygod.   Echo.    med.    du   nord.      Lille,    ii,    315,    1892. 

Cooper  and  Edv/ards.     Diseases  of  the  Rectum  and  Anus.  315,    1892. 

Phocas.  G.     Arch.  prov.  de  chir.,   Paris,   i.  407-412,    1892. 

Kasack.    M.    R.      Ueber   Coccygodynie.    Berlin.    1892. 

Harris.   A.   H.     North.   Car.  M.  J.,   Wilmington,  xxxi.  261-263,    1893. 

Barwell,  R.     Med.   Week.,  Paris,  ii.   149.   1894. 

Tilmann.     Charite-Ann.,  Berlin,  xix.  361.   1894. 

Montgomery,   E.   E.      Charlotte  N.   C.  M.  J.,  vii,   711,    1895. 

Elliott.  C.  S.     Med.   Arena,  Kansas   City.   iv.  257-262.    1895. 

Brenner.   W.     Med.  Rec,   New  York.    1,    154.    1896. 

Rohleder.    W.      Ueber    Coccygodynie.    Berlin.    1896. 

Schaffer,    O.      (Pseudococcygodynie).      Centralb.   f.    C\^nakol.,   Leipzig,   xxi,    1249-1254.    1897. 

Fletcher.   W.    B.      Indiana   M.   /..    Indianapolis,    xvi,   301-304,    1897-98. 

Borst.  Die  angeb.  Geschwulst.  d.  sacr.  Region,  Centralb.  f.  ailg.  path.  ii.  path.  anat..  Jena,  ix,  449 
501,    1899. 

Van  Lennep,  W.  B.     Hahneman  Inst.,  Philadelphia,  x.    136,   1902-3. 

Courtois-Suftt.     Ann.  d'hvg.,  Paris,  4.  s,   ii,  66-69,    1904. 

Ferrari,  G.     Policlin.  Roma.,  xii,  sez,  prat.  1190-1193,   1905. 

Sutton.  J.  B.     Clin.   /..  London,  xxxiii.  97-100.   1908-9. 

Courtois-Suffit  &   Bourgeous,  F.      Caz.  d.  hop.,  Paris,   Ixxxiii.    1945-1949.    1910. 

SURGERY  OF  THE  COCCYX. 

{Coccygectomy. 
Coccygogectomy. 
Tenotomy. 
The  propriety  of  removing  a  part  or  all  of  the  coccyx  for  anomalies,  diseases  and 
injuries  can  not  be  disputed,  nor  can  any  question  arise  for  doing  so  when  pain  or  tender- 
ness exists  without  these  conditions. 

Pag-e  Sixty-Five 


Historv. 

Coccygeciomy  has  been  done  for  deformity,  disease  and  injury  without  danger  or 
inconvenience.  Nott,  1 832,  was  first  to  report  the  removal  of  the  coccyx.  Thomas, 
1835,  removed  it  for  parasitic  infection,  and  Nott  again,  1844,  and  Simpsofr,  J.  Y., 
1861 ,  were  among  the  first  to  call  attention  to  pain,  disease  and  deformities  of  the  coccyx. 

Todd,  1874,  cured  neuralgia  of  the  coccyx  and  pelvic  viscera  by  coccygectomy. 
Blackwood,  1879,  wrote  on  the  necessity  of  accurate  diagnosis  of  fractures  at  the  sacro- 
coccygeal junction,  drawn  inward  and  the  lemoval  of  the  coccyx,  and  Stcuiford,  1879, 
and  Burt,  1881,  cases  of  pain  cured  by  removing  the  coccyx. 

Garretson,  1  881 ,  applied  the  surgical  engine  for  the  purpose  of  removing  the  coccyx. 
Guillet,  1882,  reported  a  case  of  dermoid  cyst  removed  from  the  ano-coccygeal  region 
and  Cottrell,  1  883,  reported  having  performed  Garretson's  operation  (surgical  engine) 
for  the  removal  of  the  coccyx  without  disturbance  of  the  perineum.  Imlach,  1885, 
removed  the  coccyx  for  caries,  and  Welch,  1886,  for  neuralgia,  Evans,  1887,  cured 
mental  symptoms  by  removing  a  necrosed  coccyx. 

Bowlby,  1 889,  reported  three  cases  of  coccygeal  cysts,  and  Davis,  1  892,  one  of 
extirpation  of  the  coccyx  in  which  was  located  a  congenital  cyst. 

Kasley,  1  893,  records  a  case  of  irreducible  luxation  of  the  coccyx  which  was  cured 
by  extirpation,  and  Coe,  1  895,  one  of  dermoid  cyst  of  the  coccyx. 

Adler,  1895,  cured  by  excision  of  the  coccyx  constant  pain  resulting  from  an  un- 
united fracture,  while  Brewer,  1  896,  states  that  the  knife  for  coccygodynia  is  a  failure, 
Liell,  1897,  excised  the  coccyx  in  four  cases  of  fracture  and  necrosis.  Hirst,  1897,  one 
for  ununited  fracture  and  Lange,  1897,  one  for  dermoid  cyst,  de  Vesian,  1907,  injected 
alcohol  (60  per  cent.)  about  the  coccyx  for  rebellious  pain. 

Courlois-Suffit  &  Bourgeois,  1910,  interpretated  the  medico-legal  question  of  sur- 
gical intervention  in  pain  due  to  injuries  to  the  coccyx,  thus  showing  that  there  are  many 
medico-legal  phases  concerning  this  bony  appendage. 

Berber  in  1910  ablated  successfully  a  hernia  of  the  spinal  cord  in  the  region  of 
the  coccyx  in  an  infant  as  was  also  done  by  Brad  during  the  same  year. 

Until  within  the  last  ten  years  coccygectomy  was  done  more  frequently  for  neuralgia 
than  for  all  other  causes  combined,  but  this  operation  grows  rapidly  in  favor  for  fractures, 
ankyloses  and  flailed  conditions,  especially  when  they  excite  great  general  irritability 
without  pain,  neuralgic  in  character. 

Technique. 

Coccygectomy — Complete — Incomplete. 

Complete.  Removal  of  all  the  coccyx  may  be  easily  accomplished,  with  local  or  pul- 
monary anesthesia,  preferably  local,  through  a  median  incision  extending  from  the  first 
to  the  fifth  segment,  after  separating  the  soft  parts  from  the  coccyx  with  a  periosteome  and 
dividing  the  bone  with  sharp  forceps.  The  hemorrhage  is  usually  insignificant,  but  drainage 
should  always  be  instituted,  because  of  the  great  possibility  of  infection  of  tissues  so  in- 
timately related  to  the  anus  and  vulva. 

The  same  methods  should  be  followed  with  partial  excision  of  the  coccyx,  care 
always  being  observed  in  both  instances  not  to  injuie  the  rectal  wall.  Sutures  when 
possible,  should  be  avoided  because  of  the  distress  caused  by  their  presence.  They  should 
when  necessary  be  inserted  close  to  the  edges  of  the  incised  skin,  but  many  such  incisions 
will  close  by  the  infold  of  the  cut  edges  without  suture. 

Gant,  1902,  Diseases  of  the  Rectum  and  Anus,  second  edition,  pp.  168-1  72,  tab- 
ulates 37  cases  operated  for  injuries  and  tumors. 

Personal  Coccygectomies   (Acquired) . 
3   Sarcoma,  one  5|/2  lbs.,  one  7  oz.,  and  one  2|^-^  lbs. 
2    Necrosis ;  one  syphilis,  one  tuberculosis. 

1  0   Fractures ;  four  males,  six  females. 

1  1    Neuralgia;  six  females,  five  males. 
6  Ankylosis;  four  males  and  two  females.      Two  right  angle   (males),  one  right 
angle  (female). 

Pag-e    Sixty-Six 


Cocc\)gectom^  (Congenital). 

1  long,   sharp  and   flexible,    (male). 

2  long,   sharp  and   flexible,    (female),   also  9   of  recent   date. 
Total,  44. 

TENOTOMY. 

Tenotomy,  suggested  by  J.  Y.  Simpson,  1861,  is  done  by  dividing  subcutaneously 
the  soft  structures  along  the  lateral  borders  of  the  coccyx.  This  method  has  received 
high  commendation  by  quite  a  number  of  operators  but  the  results  observed  after  three 
such  operations   upon   as  many   subjects,    by   as  many   operators,    are  not   commendable. 

Technique  for  tenotomy  may  best  be  accomplished  by  a  posterior  lateral  incision  ex- 
tending through  the  cutaneous  and  other  soft  tissues  overlying  the  coccyx,  the  incision 
being  upon  one  or  both  sides,  as  necessity  may  require.  With  the  left  index  finger  within 
the  rectum  and  upon  the  coccyx  for  a  guide,  the  danger  of  incising  the  wall  of  the  rectum 
may  be  avoided,  as  the  tendons  are  divided  at  their  attachments  along  the  lateral  bony 
borders.  The  point  of  a  narrow  bladed  knife  may  be  made  to  pass  from  the  tip  of  the 
coccyx  upward,  or  from  its  sacral  border  downward,  there  being  no  special  advantage 
with  either  course,  but  the  incision  should  extend  about  one  and  one  half  inches  downward 
from  the  tip  of  the  coccyx. 

There  may  be  difficulty  in  palpating  the  entire  rectal  surface  of  the  coccyx,  but 
this  IS  only  when  it  is  very  short  or  when  the  subject  is  extremely  fleshy,  or  of  great  height. 
This  difficulty  is  more  frequently  encountered  in  the  male  subject,  because  these  con- 
ditions may  be  overcome  by  an  examination  of  the  female  coccyx,  with  the  finger  in  the 
vagina. 

The  after  care  of  such  posterior  incisions  is  the  same  as  for  coccygectomy  already  de- 
scribed. 

Trans  rectal  tenotomy  is  a  method  not  to  be  recommended  because  the  incisions  are 
made  through  the  rectal  wall  along  the  lateral  borders  of  the  coccyx,  wath  a  knife  upnan 
a  long  handle  inserted  through  a  speculum,  thus  being  more  difficult  and  dangerous  because 
of  the  possibility  of  infection  and  hemorrhage,  sufficient  causes  for  condemnation. 

Novocain  or  cocain  injected  subcutaneously  will  suffice  for  anesthetic  purposes,  the 
pulmonary  method  being  seldom  indicated  for  either  excision  of  the  coccyx  or  incision  of  its 
tendon. 

BIBLIOGRAPHY. 

(Surgical.) 

Excision : 

Thomas.     Prov.  San.  Ber.  d.  Med.  Coll.  v.  Pommern,    i&34,  Stettin.  79-81,    1835. 

Nott,  J.  C.     Nerv  Orleans  M.  /.,   i,  58,   1834-1844. 

Simpson,  J.  Y.     Med.   Times  &  Caz.,  London,  i,  317,    1861. 

Kidd,  G.  H.  Med.  Press  &  Circ,  Dublin,  1867,  111,  596-598,  also  Dublin  Q.  /.  M.  Sc,  xliv, 
477-481,  1867. 

Bourillion.  Neciose  du  coccyx  paralysie  generale  procedee  d'un  affection  de  la  moelle  symptoms 
de  paralysis  agitans  autopsie.  Rec.  d.  trav.  Soc.  med.  d'obs.,  Paris,  1866-70,  2,  s,  li,  455-464.  .Also 
in  Caz.  d.  hop.,  Paris,  xliii,  198,  202.   1870. 

Amann,  Aertzll.  Int.  hi.,  Munchen,  xvii,  394,   1870. 

Adams,  Z.  B.     Rec.  Bost.  Soc.  M.  Improve.,   1866-74,  vi,  140;   also  Boston  M.  &  S.  /..  v,  458,   1870. 

Plum.     Hasp.   Tid.,  Kjobenhagen,  xiii,  33-35,    1870. 

Simpson.  J.   Y.      In   his   Works    (Dis.   of   Women)    Edinburgh,   iii,  202-224,    1871. 

Betz,   F.      Memorabilien,   Heilbronn,   xvi,  40,    1871. 

Seelismuller,  .\.  Coccygodynie  seit  zwolf  Jahren  bestehend,  geheilt  durch  den  faradischen  Strom. 
In  his  Neuropathol.  Beobacht.,  Halle,  25-27,   1873. 

Todd,  S.  S.     Med.  Herald,  Leavenworth,   1874-5,  viii,  99;    also  Kansas  Ciip  M.  J.,  iv,   138.   1874. 

Svenson,   I.      Upsala  Lakaref,  Fori}.,  xi,  337-339,    1875-6. 

Irish.  J.  C.     Boslon  M.  &  S.  J.,  xcii.  613,   1875. 

Mursick.  G.  A.     Am.  J.  M.  Sc,  Philadelphia,  clxi,   122-124,   1876. 

Broca.      Sur  un   cas   de    traumatisme    frave    du   coccyx   ayant   necessite    la    resection.      Tribune    med 
Paris,  xii,    112-114,    1879. 

Pag:e  Sixty-Seven 


Blackwood,  W.  R.  D.  Ptoc.  Phila.  Co.  M.  Soc,  Philadelphia,  1880,  ii,  56,  also  PhUa.  M.  Times, 
X,  295,  1879-80. 

Stanford,  F.  A.     A'en>   York  M.  J.,  xxx,  400,   1879. 

Burt,  W.  J.     Mississippi   Valley  M.  Month.,  Memphis,   1,   1-4,   1881. 

Garretson.     Phila.  M.   Times,  xii,  303,    1881-2.  ^ 

Guillet.     /.  de  Med.  de  I'Ouest,  Nantes,  xvi,  240,   1882. 

Binzer.     Gl;nae^.  og  obsL  Medd.  Kjobenhagen,   iv,    1,   2,   Hft.  52-61,    1882. 

Browne,  B.  B.     Maryland  M.  J.,  Baltimore,  ix,  284,   1882. 

Marr,  L.     Hosp.   Tid.,  Kjobenhagen,  2,  R,  ix,  284,   1882. 

Ward.     yVen>  Yor^M.  /.,  xxxvi,  70,   1882. 

Werner,    Marie.     B.  Med.   &  Surg.  Reporter,   Philadelphia,   xlviii,  287,    1883. 

Cottrell,  3.  P.     Independ.  PracL,  New  York,  iv,  8-10,    1883. 

Dawson,  B.  F.     Am.  ].  Obst.,  New  York,  xvi,  II 89,  1883. 

Harrison,  G.  T.     New   York  M.  J.,  xxxvii,  268,   1883. 

Macdonald,  A.      Tr.  Edinb.  Ohsl.  Soc,  x,   183,   1884-5. 

Goodell,  W.     Med.  &  Surg.  Reporter,  Philadelphia,   1,  588,   1884. 

Browne,  B.  B.     Maryland  M.  J.,   Baltimore,  xiii,  26,    1885. 

Tilaux.     Practicien,  Paris,  viii,  293-295,   1885. 

Imlach.     Brit.  Gpnec.  /.,  London,  i,  319,    1885. 

Welch,  C.  T.     Tr.  M.  Soc.,  New  Jersey,  Newark,  288.   1886. 

Whitehead,  W.     Lancet,  London,  i,    112,   1886. 

Odell,  W.     Lancet,  London,  i,   1088,    1887. 

Evans,  Z.  H.     Phila.  M.  Times,  xviii,  351,   1887-8. 

von  Swiecicki.      Wien.  med.  Presse,  xxLx,   1136,   1888. 

Bowlby,  A.  A.     Tr.  Path.  Soc,  London,  xli,  284-289,   1889-90. 

Post,  A.    Boston  M.  &  S.  /.,  cxxiii,  300,  1890. 

Sutton,  B.     Med.  Presse  &  Circ,  London,  ns,  liv.,  607,   1892. 

Lucy.     Lancet,  London,  ii,   1046,    1892. 

Davis,  E.  P.     Am.  Gijnec.  &  Pediat.,  Philadelphia,  vi,  542,    1892-3. 

Pine,  Aleinda  A.     Northwest  Lancet,  St.  Paul,  xii,   180-182,   1892. 

Early.  T.  B.     Med.  Ball.,  Philadelphia,  xv,   138,   1893. 

Coe,  H.  W.     Pacific  M.  Rec,  Portland,  Ore.,  i,  78   1893. 

Adler,  L.  H.^    Jr.  Med.  News,  Philadelphia,  Ixvii,  348,   1895. 

Jackson,  J.  N.     Langsdale's  Lancet,  Kansas  City,  i,  299,    1896. 

Bremer,  L.     Med.  Rec,  New  York,    1,    154,    1896. 

Liell,  E.  N.     Med.  News,  New  York,  Ixx,  382,    1897. 

Hirst,  B.  G.     Am.  J.  Obst.,  New  York,  xxxv,  794,   1897. 

Lange,  K.     Eira,  Stockholm,  xxi,  352,    1897. 

De  Vesian.     Rev.  Prat,  de  g\^nec.  d'obst.  el  de  pediat.,   Paris.  Ixxxii,  206-263,   1907. 

Irwin,  J.  R.     Charlotte   (N.  C.)  M.  J.,  Iviii,   170,   1908. 

Pons.     Kyste  dermoide  de  la  region  coccygienne.     Marseille  med.,  xlvl,    167-169,   1909. 

Cortois-Suffit  &  Bourgois,  F.     Soc.  de  med.   leg.   de  France  Bull.,   Paris,   xhi,  239-255,    1910. 

MISCELLANEOUS  BIBLIOGRAPHY.     (Coccyx.) 

Miscellaneous   Bibliography. 

Krimer,  W.  Bruch  des  Steissbein's,  Ursache  langjahrner  Nervenleiden.  Med.  ConVers.  Bl.,  Hud- 
burgh,  1,  93-96,  1830. 

Godfrey,  A.     Am.  J.  M.  Sc,  Philadelphia,  ns,  xhi,  576,   1860. 

Broers,   H.   J.      Bijeen   Jong  meisie.   Nederl.    Tifdschr.,   v,    Heelen   Verlosk,    Utrecht,   xiii,    595-601, 

1862-3. 

Horschelmann.     St.  Petersb.  med.  Ztschr.,  iii,   117-120,   1862. 

Betz,  F.  Ueber  den  wahrend  der  Geburt  entstehenden  Steissbeinbruch.  Memorabilien,  Heilbronn, 
X,  58-62,  1865. 

Arnold,  J.     Zur  Steissdriisenfrage.     Arch.  f.  path,  anal.,  Berlin,  xxxiii,  454-456,  1865. 

Arnold,  J.  Ein  weiterer  Beitrag  zu  der  Steissdriisenfrage.  Arch.  f.  anal.,  Berlin,  xxxv, 
220-223,   1866. 

Fox,  W.  R.     Chicago  M.  Exam.,  xl,  76,   1870. 

Gilette.     Courrier  med..  Pans,  xxiv,  235,   1874. 

Lanz,  E.     Ueber  die  Beweglichkeit  des  Steissbeines  und  ihre  Beziehung  zu  der  Geburt.     Bern,   1878. 

Greve.     Ein  Fall  von  Schwanzbildung  beim  Menschen.     Arc.  f.  path,  anal.,  Berlin,  Ixxii,   129,   1878. 

Ornstein.      Schwanzbildung   beim   Menschen.      Verhandl.    d.    Berl.    Cesellsch.   f.   AnthropoL,    Berlin. 

303-305,  1  pi,  1879. 

Post.     Disease  of  coccyx.     A^eD;   York  M.  J.,  xxx,   517,    1897. 

Bartels,  M.     Eine  schwanzahnliche  Neubildung  beim  Menschen.     Arch.  f.  path,  anal.,  Berlin    Ixxxiii 

189-192,  1  pi.,  1881. 

Virchow,  R.     Schwanzbildung  beim  Menschen.     Arch.  f.  path,  anal.,  Berlin,  Ltxxiii,  560,  I  pi.,  1881. 
Schmidt,   M.      Zwei   Falle  von   Geschwiilsten   in   der  Gegend  des   Schwanzbeines.     Arb.   a.   d    chir 
Univ.  Poliklin.,  zu  Leipzig,  2  Hfte.,   15-22,   1892. 

Blum,   F.     Die  Schwanzmuskulatur  des   Menschen    (Freiburg  i.   B.)    Wiesbaden,    1894. 

Page  Sixty-Eight 


CHAPTER  IX. 


URETHRA. 


ANATOMY. 

ITH  THE  exception  in  length  of  the  urethra,  the  urinary  apparatus 
in  the  male  and  female  are  similar,  especially  alike  from  the 
lower  portion  of  the  bladder  to  and  including  the  kidneys. 

The  urethra  m  the  male  is  of  two  portions,  approximately 
less  than  2-3  cm.  long  from  the  bladder  to  the  opening  of  the 
ducts  of  reproduction,  the  membranous  portion  1  cm.  and  the 
distal  or  spongy  portion  terminating  with  the  external  meatus,  I  4 
cm.  long  and  is  lined  with  a  mucous  membrane  throughout. 

It  contains  much  fibrous  tissue  with  the  muscular  coat  of 
circular  and  longitudinal  fibers,  intermingled  with  many  lymphatic 
glajids.  Stripped  muscle  fibers  are  present  in  the  outer  aspect  of 
the  muscular  coat  of  the  urethra,  forming  a  complete  ring  or 
sphincter  in  the  upper  part,  while  the  lower  fibers  form  the  uro- 
genital sphincter. 

An  imperforate  urethra,  when  complete  in  the  unborn,  is 
said  by  Deaver  to  always  cause  death  before  delivery,  but  two  personal  experiences  do 
not  bear  out  this  statement. 

Urethral  blood  supply  is  from  the  spermatic  or  ovarian  internal  iliac,  visceral 
vessels,  inferior  renal  arteries,  inferior  vesical  and  middle  hemorrhoidal  arteries. 

Urethral  nen>es  are  from  the  pudlc  which  carry  sensory  fibers  to  the  mucous 
membrane  and  motor  fibers  to  the  striped  muscle,  and  from  the  hypogastic  and  renal 
plexus  of  the  sympathetic  by  way  of  the  prostatic,  cavernosus  plexuses  and  pelvic 
sympathetic  plexuses. 

The  compressor  urethra  is  also  dominated  by  branches  of  the  pudlc  nerve.  Its 
function  is  to  constrict  the  membranous  urethra  in  the  male  and  flatten  the  walls  of 
the  vagina  in  the  female. 

The  lymphatics  of  urethra  in  the  male  (Sappy)  arise  from  a  network  attached 
to  the  mucous  membrane  from  the  utricle  to  the  meatus  urinarlus.  Posteriorly,  the 
network  formed  by  these  vessels  and  by  the  anastomosis  which  unites  them,  is  con- 
tinued on  the  vesiculae  semlnales  and  the  vasa  deferentla. 

In  front  it  is  continuous  with  the  tortuous  branchlets  on  the  surface  of  the  gland. 
This  network  has  an  exceptional  arrangement;  the  larger  and  smaller  branches  which 
form  It,  follow  the  direction  of  the  urethral  walls  by  many  transverse  and  oblique 
anastomoses;  they  unite  very  frequently  and  are  grouped  in  parallel  and  unequal  bundles, 
separated  by  longitudinal  ridges.  From  this  network  emanate  several  collecting  trunks 
which  may  be  divided  into   four  groups. 

The  onl\)  collecting  trunks  which  Sappy  mentions,  are  those  which  come  from  the 
mucous  membrane  covering  the  glands.  They  transverse  the  Inferior  wall  of  the 
urethra  at  the  level  of  the  fraenum,  unite  with  the  lymphatic  trunks  coming  from  the 
glans,   <Jid   terminate  in   the  same  manner   as   those  vessels. 

The  collecting  trunks  which  come  from  the  remainder  of  the  penile  portion  vary 
in  number.  They  emerge  on  the  Inferior  surface  of  the  penis,  turn  round  the  lateral 
surfaces    of    the   corpus    cavernosa    and    unite    ^\'ith    trunks    coming    from    the    glandular 


Page   Sixty-Nine 


portion.  The  majority  run  to  and  terminate  in  the  same  way  as  the  latter,  but  some 
take  an  entirely  different  course,  for  instance,  one  of  these  vessels  passes  over  the 
symphysis,  runs  between  the  two  recti  muscles,  then  turns  directly  to  the  left  and 
terminates  in  the  internal  retro-crural  gland.  More  rarely  it  may  be  found  to  terminate 
in  the  middle  gland  of  the  internal  chain  of  the  external  ihac  glands.  Kuttner  was 
the  first  to  note  the  presence  of  the  vessel,  but  he  was  wrong  in  believing  that  it  came 
from  the  mucous  membrane  of  the  glans.  A  second  collector  passes  underneath  the 
symphysis  and  unites  with  the  vessels  coming  from  the  bulbar  and  membranous  portions 
of  the  urethra. 

The  lymphai'ics  of  the  bulbar  and  membranous  portions  end  in  three  systems  of 
collecting   trunks. 

One  of  the  vessels  makes  its  appearance  on  the  upper  surface  of  the  bulb  in  the 
angle  formed  by  the  divergence  of  the  two  corpora  cavernosa.  It  embraces  either  the 
tiansverse  artery  of  the  bulb,  or  the  artery  to  the  corpus  cavernosum,  it  then  becomes 
a  branch  of  the  trunk  of  the  internal  pudic  artery  and  terminates  in  the  gland  attached 
to  the  intra-pelvic  portion  of  the  trunk  of  this  artery. 

A  second  vessel  runs  toward  the  posterior  surface  of  the  symphysis  and  then  behind 
the  pubes  to  terminate  in  the  internal  retro-crural  gland. 

A  third  trunk  ascends  on  the  anterior  surface  of  the  bladder,  and  unites  with  the 
trunks  coming  from  the  inferior  segment  of  this  surface,  and  terminates  with  the  latter 
in  the  middle  gland  of  the  internal  chain  of  the  external  iliac  glands. 

The  lymphatics  of  the  prostatic  portion  pass  into  the  collecting  trunks  which  emerge 
from  the  glandular  parenchyma. 


ETIOLOGY. 


Anomalies,  Diseases  and  Injuries. 

Anomalies. 

Diseases.    I   ?5"^.g"- 

(^   Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  of  the  urethra  may  be  congenital  or  acquired,  primary  or  secondary, 
vary  in  length,  diameter,  regularity,  location  of  external  opening,  relation  to  other 
structures,  entire  absence,  number  of  channels,  the  distal  opening  may  be  into  the 
rectal,  vaginal,  uterine  or  peritoneal  cavity,  one  or  all  in  the  same  individual,  or  there 
may  not  be  any  opening,  as  shown  by  an  imperforate  urethra,  when  the  urethra  is 
otherwise  normal.  Hypospadias  and  epispadicis  are  not  uncommon  forms  of  embryonic 
ducts,  and  about  40  per  cent,  of  those  so  afflicted  are  also  defective  mentally. 


DISEASES. 

Benign.     Malignant. 
BENIGN. 

Benign  diseases  include  those  not  cancerous  in  character,  though  they  may  be 
otherwise  malignant. 

Urethritis  may  be  primary  or  secondary,  acute  or  chronic,  local  or  general,  mild 
or  severe. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  in  any  tissue  or  portion  of  the  urethra. 

Page  Seventy 


Papillomala  in  the  urethra  may  be  congenital  or  acquired,  primary  or  secondary, 
single  or  multiple,  vary  in  size,  location,  disappear  spontaneously,  develop  sufficiently 
to  cause  obstruction,  exist  indefinitely  and  necessitate  removal,  after  which  they  may 
again  appear.     Usually  pedunculated. 

Polypi  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number,    location,    usually   pedunculated,    and   sometimes    disappear    spontaneously. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  location,  disappear  spontaneously,  or  develop  sufficiently  to  cause  ob- 
struction, usually  have  a  broad  base,  exist  indefinitely  and  necessitate  removal,  after 
which  they  may   again   appear  upon  the  mucous  membrane. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape,  location,  disappear  spontaneously,  or  develop  sufficiently  to  cause 
obstruction,  usually  appear  in  the  wall  of  the  urethra,  and  develop  in  the  surrounding 
tissues,  external  to  the  wall. 

Tuberculosis  may  be  primary  or  secondary,  single  or  multiple,  acute  or  chronic, 
in  the  mucosa  or  muscularis,  and  usually  in  the  membranous  or  prostatic  urethra;  but 
rare  in  occurrence. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  in  the  mucous  or  muscular  fibers  of  the  urethra,  usually  in  the  mem- 
branous, prostatic  or  anterior  portion. 

Concretions  and  Foreign  Bodies  may  enter  from  without  or  within,  the  most 
common  source  being  from  the  bladder  where  they  have  formed  or  have  escaped  from 
the  kidneys  or  ureters,  though  they  may  be  formed  in  the  urethra  alone,  especially  in 
the  prostatic  portion,  single  or  multiple  and  vary  in  size,  shape  and  consistency. 

Strictures  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
partial  or  complete,  in  any  portion  of  the  urethra,  and  result  from  injury  or  disease. 
Occasionally  they  will  open  spontaneously,  but  such  a  resolution  is  indeed  rare. 

Cysts  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
usually  in  any  portion  of  the  wall  of  the  urethra,  contain  blood,  pus,  serum  or  urine, 
and  rupture  externally  through  the  soft  structures,  into  the  rectum,  vagina,  uterus,  bladder 
and  occasionally  into  the  peritoneal  cavity. 

Fistulae  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
acute  or  chronic,  open  externally  upon  the  cutaneous  structures,  into  the  rectum,  vagina, 
uterus,  bladder,  seminal  ducts,  or  peritoneal  cavity,  one  or  all,  at  the  same  time,  in 
one  individual. 

MALIGNANT. 

Carcinomata  are  the  most  frequent  forms  of  cancer,  and  they  may  be  primary  or 
secondary,  usually  primary,  occur  anywhere  upon  the  mucosa,  or  muscularis,  especially 
in  the  membranous  or  prostatic  portion,  the  most  frequent  origin  being  in  the  mucosa. 

Sarcomata,  of  rare  occurrence,  may  be  primary  or  secondary,  usually  primary  zmd 
single,  and  occur  more  frequently  in  the  muscularis,  in  any  portion  of  the  urethra,  usually 
in  the  posterior. 

INJURIES. 

Lacerations,  Incisions,  Punctures  may  be  single  or  multiple,  complete  or  incomplete, 
from  without  or  within  any  portion  of  the  urethra,  the  result  of  accident  or  design. 
They  may  complicate  the  rectum,  vagina,  bladder,  uterus,  peritoneal  cavity,  perineal 
body,  seminal  ducts,  testicles  or  scrotum. 

SYMPTOMS. 

Urinary  (Male  and  Female). 

Reflex  disturbances  in  the  urinary  tract  vary  slightly  in  the  sexes  because  of 
anatomical   arrangement,   but   the   variation   is   so  slight   that  it   is   almost   impossible  to 

Page  Seventy-One 


define  them  physiologically.  It  will  therefore  be  necessary  to  consider  each  of  the 
four  divisions  of  the  tract  singly  and  collectively  for  a  more  perfect  understanding  of 
their  correlated  symptoms. 

Pain,  induration  and  tenderness  are  first  and  most  prominent  in  any  of  the  anomalies 
or  diseases  ascribed  to  the  urethra  but  localized  or  general  pain  is  not  always  an  in- 
dication that  its  cause  is  in  any  of  the  urethral  tissues.  The  intimate  relation  of  these 
structures  with  those  of  the  erectile  body  so  rich  in  nerve  fibers,  both  sensory  and 
motor,   and  blood  and  lymphatic  vessels  give  to  it  a  very  high  degree  of  sensibility. 

Pathology  of  any  character,  especially  the  obstructive  form,  including  foreign 
bodies  and  concretions  in  the  urethra  and  the  bladder,  ureters  and  kidneys,  may  cause 
impulses  to  be  transmitted  downward  to  the  distal  end  of  the  erectile  body  in  both  sexes 
because  the  seime  group  of  nerves  are  carriers  of  impulses  to  and  from  the  kidneys,  ureters, 
bladder  and  prostate. 

It  would  therefore  seem  unreasonable  for  such  a  complex  relation  of  sensory  and 
sympathetic  nerve  fibers  to  carry  impulses  at  all  times,  independently.  The  motor  fibers 
of  the  pudic  nerve  which  dominate  the  compressor  urethra  in  the  male,  the  function  of 
which  is  to  constrict  the  membranous  urethra  in  the  male  and  flatten  the  walls  of  the 
vagina  in  the   female,   are  exemphfications   of  their   duality. 

Urinary  disturbances  of  the  urethra  must  necessarily  exist  when  the  upper  tracts 
are  primarily  involved  because  the  urethra  is  the  channel  through  which  the  urine  with 
its  constituents  must  escape.  These  disturbances  may  exist  independently  and  there- 
fore possess  the  same  indications,  but  the  disturbances  which  the  bladder,  ureter  and 
kidneys  produce,  are  more  severe  and  serious.  The  urethra  being  the  most  available 
portion  of  the  urinary  tract  for  examination,  does  not  necessitate  so  great  a  classification 
of  symptoms  for  diagnosis  except  so  far  as  its  physiological  effects  upon  other  tissues 
and  organs  are  concerned. 

Vascular  changes  are  proportionate  with  the  rate  of  pulse,  though  there  may  not 
be  any  perceptible  difFerence  in  the  earlier  periods. 

Arterio-vascular  disturbances  in  the  urethra  are  quite  common  and  varied,  as  they 
are  in  the  general  urinary  system.  Their  progress  and  severity  are  determined  by  the 
rate  and  quality  of  the  pulse  especially  when  the  bladder,  ureters,  or  I^idne^s  are  in- 
volved by  infection  of  various  kinds  with  or  without  increase  of  temperature.  The  pulse 
may  intermit  or  be  otherwise  irregular,  such  being  especially  observed  in  senility. 

Urethral  changes  are  less  likely  to  cause  such  disturbances  though  they  may  do 
so  when  far  advanced,  especially  in  severe  urethritis  due  to  gonococci. 


Page  Seventy-Two 


CHAPTER  X. 


BLADDER, 


ANATOMY. 

i«^  ^^        ^^  J^    HE  BLADDER   has  been  constant   from   the  beginning  with   all 
^1*^  £  I  W  forms  of  animal  life,  that  it  may  receive  urine  indirectly  by  means 

Clvvl       K^>^^  of  folds  of  mucous  membrane  when  the  ureters  do  not  enter  di- 

rectly into  it,  or  directly  when  they  enter  the  bladder.  It  is 
largest  at  its  base  and  varies  in  size  and  shape,  very  distensible, 
located  in  the  extreme  lower  pelvis  and  richly  endowed  with 
blood,  lymphatic  vessels,  glands  and  nerve  fibers. 

It  varies  in  thickness  because  of  being  distended  and  is 
composed  of  mucosa  within,  a  serosa  without,  and  muscular 
fibers  between  the  two  layers. 

Its  blood,  lymphatic  and  nerve  supplies  are  alike  in  the 
male  and  female. 

The  blood  suppl);  is  from  the  superior  middle  and  inferior 

vesicle,  obturator  and  internal  pudic  arteries  and  branches  of  the 

uterine  and  vaginal  arteries  in  the  female. 

The  venous  plexus  about  the  organ  is  larger  at  its  base  and  communicates  with  the 

prostatic  plexus  from  the  vesico-prostatic  plexus  which  empties  into  the  internal  iliac  vein. 

Its  fundus  or  base,  spermatic  ducts,  and  recto-vesical  pouch  are  directed  toward  the 

rectum,   and  in  the  female,   is   attached  to  the  anterior  vaginal  wall. 

The  arteries  are  chiefly  the  inferior  and  superior  vesical  from  the  anterior  division 
of  the  internal  iliac,  reinforced  by  branches  from  the  middle  hemorrhoidal  and  twigs 
from  the  internal  pudic  and  obturators. 

Nerves  include  sympathetic  and  spina]  fibers;  the  sympathetic  follow  the  arteries 
and  join  the  vesical  branches  from  the  sacral  plexus  which  is  derived  from  the  3rd  and 
4th  and  possibly  the  2nd  sacral  spinal  nerves. 

The  larger  nerves  divide  in  the  outer  fibrous  coat  of  the  bladder,  into  small  fibers 
that  are  connected  with  ganglia  especially  near  the  ureters. 

The  bladder  in  general  is  but  a  trifle  sensitive,  but  it  is  very  sensitive  about  the 
entrance  of  the  ureters  into  the  bladder  at  which  point  nerve  fibers  predominate. 

Fibers  from  the  pelvic  plexuses  of  the  sympathetic  and  third  and  fourth  sacral  nerves 
supply  the  urinary  bladder,  while  fibers  from  the  sympathetic  plexuses  supply  the  ureters 
and  fibers  from  the  hypogastric  plexuses  of  the  sympathetic  with  central  fibers  mingled 
with  Pacinian  corpuscles,  inhibit  the  prostate  gland. 

Tlie  lymphatics  of  the  bladder.  The  only  network  of  origin  which  exists  in  the 
bladder  is  an  intramuscular  one.  The  emergent  vessels  of  this  network  end  in  a  second 
network  placed  on  the  outer  surface  of  the  vesical  muscle,  under  the  peritoneum  of  the 
umbilico-praevesical  fascia.  The  course  and  termination  of  the  collectors  of  this  net- 
work vary  according  to  their  situation  on  the  anterior  or  posterior  surface  of  the  bladder. 
Anterior  surface.  The  collecting  trunks  coming  from  the  anterior  surface  form 
two  groups.  The  trunks  coming  from  the  inferior  segment  of  this  surface  run  almost 
transversely  outward,  and  pass  into  a  gland  placed  on  the  lateral  surface  of  the  pelvic 
cavity,  between  the  external  iliac  vein  and  the  obturator  nerve,  a  few  millimeters  behind 
the  cervical  ring.  The  trunks  which  come  from  the  superior  part  of  the  anterior  surface 
are  remarkable  for  their  sinuosities.     They  run  upwards  and  outwards,  cross  the  hypo- 


Page  Seventy-Three 


gastric  artery,  passing  either  above,  or  not  frequently  below  it,  and  eventually  terminate 
in  the  middle  gland  of  the  middle  chain  of  the  external  iliac  group.  In  the  course  of 
these  lymphatic  trunks  are  placed  small  glands,  which  are  only  visible  after  injection, 
they  belong  to  the  group  of  interrupting  glomular  nodules.  Some  of  these  glaftds  are 
placed  in  front  of  the  bladder  (pre-vesical  glands) ,  they  maj'  become  hypertrophied  in  cer- 
tain pathological  conditions  (Bazy)  and  may  form  the  starting  point  of  certain  prae-vesical 
phlegmons.  Others  are  placed  at  the  spot  where  the  lymphatic  vessels  cross  the  hypo- 
gastric artery,   (latero-vesical  glands.     Waldeyer,  Gerota). 

Posterior  surface.  The  trunks  which  come  from  the  posterior  surface,  also  form 
several  groups. 

The  trunks  which  come  from  the  superior  portion  of  this  surface  run  outwards 
describing  several  curves.  They  cross  the  hypogastric  artery,  where  they  traverse  some 
small  lateral-vesical  glands,  and  terminate  in  the  external  iliac  gland  in  which  the  superior 
lymphatics  of  the  anterior  surface  also  end. 

Other  trunks  pass  backwards  following  the  course  of  hypogastric  artery,  and  end 
in  a  gland  which  is  situated  like  the  preceding,  on  the  external  iliac  vein,  but  more 
posteriorly  to  it,  immediately  in  front  of  the  bifurcation  of  the  common  iliac  artery. 

Other  trunks  which  come  from  the  middle  segment  of  the  posterior  surface,  end 
in  the  hypogastric  glands. 

Others  finally  arising  from  near  the  neck  of  the  bladder  run  directly  backwards, 
and  crossing  the  lateral  surface  of  the  rectum,  ascend  onto  the  anterior  surface  of  the 
sacrum  and  terminate  in  the  glands  situated  in  the  angle  of  bifurcation  of  the  abdominal 
aorta,  in  front  of  the  promontory. 

The  vesical  lymphatics  end  in  the  glands  of  the  bifurcation  of  the  aorta.  We  may 
add  that  the  prae-vesical  network  is  continuous  with  the  network  which  surrounds  the 
prostate,  the  vesiculae  seminales,  the  vasa  deferentia,  and  the  terminal  parts  of  the  ureters. 

Etiology. 

Anomalies,   Diseases   and  Injuries. 
Anomalies. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  inverted,  ex- 
ceedingly large  or  small,  entirely  absent,  open  upon  the  abdominal  wall,  (exstrophy), 
abnormally  placed  in  the  pelvis,  partially  or  completely  septinated,  or  contain  two 
or  more  cavities,  when  the  urachus  is  present. 

Ectopy  is  evidenced  by  the  bladder  protruding  through  a  cleft  in  the  abdominal 
wall. 


DISEASES. 

Benign.     Malignant. 
BENIGN. 

Cystitis  may  be  primary  or  secondary,  acute  or  chronic,  local  or  general,  mild 
or  severe. 

Atrophy  may  be  congenital  or  acquired,  primary  or  secondary,  local  or  general. 
Usually  in  all  of  the  structures. 

Pag-e  Seventy-Four 


H^perlroplt^  may  be  congenital  or  acquired,  local  or  general  in  any  one  or  all 
of  the  structures,  usually  all,  primary  or  secondary. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  depth,  due  to  trauma  or  infection,  acute  or  chronic,  in  any  tissue  or  portion 
of  the  bladder  wall,  cease  or  continue  in  size  or  disappear  spontaneously. 

Fissures  at  the  neck  may  be  congenital  or  acquired,  usually  acquired,  acute  or 
chronic,  single  or  multiple,  primary  or  secondary,  usually  in  the  mucosa,  sometimes 
the    muscularis. 

Papillomata  are  probably  the  most  frequent  forms  of  new  growth  in  the  bladder.  They 
may  be  congenital  or  acquired,  single  or  multiple,  upon  any  portion  of  its  inner  surface, 
develop  to  considerable  size,  remain  quiescent  or  disappear  spontaneously,  though  such 
a  resolution   seldom   occurs. 

Ader\orr\ala  frequently  found  in  the  bladder,  may  be  congenital  or  acquired,  single 
or  multiple,  (usually  multiple),  upon  any  portion,  small  or  large,  cease  to  develop  but 
seldom  disappear  spontaneously. 

Polypi  may  be  congenital  or  acquired,  single  or  multiple,  large  or  small,  pedun- 
culated, vary  in  shape  and  location. 

Fibromata  may  be  congenital  or  acquired,  single  or  multiple,  usually  single,  in  any 
portion  of  the  muscularis,  where  they  originate,  remain  small,  become  large,  cease  to 
grow,  or  disappear  spontaneously. 

Myomaia  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size, 
shape,   number   and  location. 

Angiomala  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
vary  in  size,  number  and  location  and  disappear  spontaneously. 

Liponiata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size, 
shape,   location   and  number. 

Chondromala  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size, 
shape,    location    and    number. 

Tuberculosis  may  be  primary  or  secondary,  single  or  multiple,  acute  or  chronic, 
involve  any  part  or   all   of  the  bladder,   or   disappear  spontaneously. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
in   any  portion   or  all   of  the  bladder. 

Parasites  may  be  congenital  or  acquired,  primary  or  secondary,  without  or  within, 
become  encysted,  or  remain  in  the  bladder  cavity,  the  most  common  being  cysticircus. 
Any  form  may  be  temporary  or  become  permanent. 

Concretions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  location,  encysted  in  any  portion  of  the  wall  of  the  bladder,  especially 
in  its  lower  extremity,  originate  in  the  kidney  or  ureter,  and  pass  into  the  bladder. 

Foreign  Bodies  may  be  introduced  by  accident  or  design,  be  single  or  multiple,  enter 
from  ^vithout  or  within,  through  the  urethra,  surrounding  soft  structures,  ureters,  uterus 
or  peritoneal  cavity  and  escape  from  the  bladder  into  any  one  or  more  of  these  cavities  or 
tissues. 

Cysts  may  be  congenital  or  acquired,  single  or  multiple,  large  or  small,  in  any  portion 
of  the  bladder  wall,  contain  pus,  blood,  serum,  urme  or  parasites,  such  as  ecchinococci, 
or  other  forms,  rupture  into  the  rectum,  vagina,  uterus,  peritoneal  cavity,  bladder,  urethra, 
or   soft   structures   externally. 

Fislulae  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
acute  or  chronic,  vary  in  size  and  length,  through  any  portion  of  the  bladder  wall, 
open  externally  through  the  soft  structures  into  the  rectum,  vagina,  uterus,  peritoneal 
cavity,   urethra  or  seminal  vesicles. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  usually  primary  and  single,  in  2uiy 
portion  of  the  bladder  wall  and  of  slow  or  rapid  growth. 

Page  Seventy-Five 


Sarcomata  may  be  primary  or  secondary,  usually  primary  and  single,  upon  any  portion 
of  the  bladder  wall  and  slow  in  their  development. 

INJURIES. 

Herniae  of  the  bladder,  usually  in  the  groin,  may  be  congenital  or  acquired,  into 
the  rectum,  vagina,  through  the  inguinal  canal  or  abdominal  wall,  of  rare  occurrence, 
but  sufficiently  frequent  to  require  consideration.  The  inguinal  variety  is  almost  always 
unilateral,  the  perineal  usually  due  to  pregnancy,  the  urethral  is  the  inversion  of  the 
bladder,  occurs  only  in  the  female,  the  crural  form  exceedingly  rare. 

Ruptures  may  be  by  accident  or  design,  primary  or  secondary,  complete  or  incom- 
plete, single  or  multiple,  due  to  force  applied  from  without  or  within,  in  any  portion 
of  the  bladder  wall,  extend  into  the  peritoneal,  uterine,  rectal  or  vaginal  cavities, 
complicate  ureters.  Fallopian  tubes,  bloodvessels,  nerves,  lymphatics,  intestines,  cutaneous 
structures   or   abdominal   wall. 

Incisions  may  be  by  accident  or  design,  single  or  multiple,  penetrating  or  non- 
penetrating, from  without  or  within,  to  the  same  degree  as  rupture. 

Punctures  may  be  by  accident  or  design,  single  or  multiple,  penetrating  or  non- 
penetrating, without  or  within,  through  any  of  the  overlying  structures,  involve  any  of 
the  associated  organs,  through  the  rectum,  vagina,  urethra,  or  peritoneal  cavity. 

SYMPTOMS. 

Symptoms  pertaining  to  the  urinar^)  bladder  are  quite  varied  and  uncertain,  especially 
because  of  the  great  variety  of  conditions  found  within  its  structures,  and  the  adjacent 
soft  tissues,  and  because  of  their  inhibition  being  from  the  same  source,  and  similar 
in  both  sexes.  Any  one  of  the  conditions  herein  ascribed,  involving  the  bladder,  may 
cause  subjective  symptoms  identical  in  character. 

It  is  inhibited  by  both  motor  and  sensory  fibers  from  the  pelvic  plexus  of  the 
sympathetic,  and  third  and  fourth  sacral  nerves,  and  therefore  must  be  a  source  of  great 
general  disturbance  within  the  uro-genital  and  rectal  tracts,  especially  as  their  fibers 
coalesce  with  the  motor  and  sensory  fibers  of  other  nerves.  The  bloodvessels  and 
lymphatics  alike  coalesce  with  their  associates,  adding  greatly  to  this  general  disturbance. 

Local  manifestations  in  the  bladder  such  as  tenderness  and  pain  may  or  may 
not  vary  with  the  degree  of  involvement  as  may  those  that  are  general,  which  are  indicated 
by  increased  sensibility,  pain,  chill,  headache,  shock,  with  added  nausea  and  vomiting. 

The  effect  of  neuroses  of  any  character  upon  the  urinary  system  and  its  associated 
structures  or  organs,  is  shown  by  the  frequent  desire  to  void  urine.  Incontinence  or  reten- 
tion may  also  occur  as  may  tenesmus  or  the  sensation  of  burning  be  induced  by  nervous 
irritability. 


Page  Seventy-Six 


CHAPTER  XI. 


URETER. 
ANATOMY. 


>^  ^-^       ^^    jr>    HE  URETER  is  composed  of  mucous,  muscular  and  fibrous  coats 
^  I^  Sf  w  rather  thick  and  white. 

C/^/^  >^\^^  ^/ic  mucous  membrane  has  many  layers  of  epithelial  cells, 

and  the  muscular  coat  is  composed  of  unstriated  muscle  fibers  in 
bundles  which  are  separated  by  connective  tissue  and  arranged 
longitudmally  and  cnxularly. 

The  fibrous  coal  varies  in  thickness  at  different  levels,  the 
lower  part  blending  with  the  connective  tissue  which  lies  among 
the  muscle  fibers  forming  the  sheath  of  the  ureter. 

In  the  female  about  three  inches  can  be  palpated  through 
the  vagina. 

The  ureters  extend  from  the  bladder  backwards,  outward 
and  upward  to  the  base  of  the  broad  ligaments  and  toward  the 
lateral  walls  of  the  true  pelvis. 

The  ureters  are  behind  the  peritoneum  covering  the  psoas 
muscle  and  in  front  of  the  common  iliac  arteries,  and  in  the  true  pelvis  in  front  of  the  in- 
ternal iliac  arteries,  entering  the  bladder  about  one  inch  apart. 

Blood  supp/l;  is  from  the  renal  and  spermatic  arteries  in  its  abdominal  portion 
and  the  superior  vesical  and  the  middle  hemorrhoidal  vessels  in  its  pelvic  portion. 
Nerve  supply  is  through  the  renal,  the  spermatic  and  hypogastric  plexuses. 
Lymphatics  of  the  Ureter.  Our  knowledge  of  the  lymphatics  is  still  imperfect. 
Sappy  was  able  to  inject  them  only  in  the  horse,  and  met  with  them  only  in  the  muscular 
coat.  In  the  course  of  his  injections  of  the  vesical  lymphatics  several  times  he  has 
seen  the  subserous  network  of  the  bladder  extend  itself  a  few  millimeters  round  the 
ureter.  The  lymphatics  of  the  ureter  end  in  multiple  collecting  trunks  which  pass  to 
the  neighboring  glands. 


ETIOLOGY. 


Anomalies,  Diseases  and  Injuries. 

Anomalies. 
,g     f   Benign. 
1^   Malignant. 
Injuries. 


Di 


ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  length,  size,  origin,  entrance  into  the  bladder,  course  and  relation  to  other 
structures,  one  or  both  absent,  the  right  enter  the  bladder  upon  the  left,  the  left  upon  the 
right  side,  or  anywhere  upon  the  surface. 


Page  Seventy-Seven 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Urethritis  may  be  primary  or  secondary,  acute  or  chronic,  and  involve  any  part 
or  all  of  the  mucosa. 

Tuberculosis  may  be  acute  or  chronic,  primary  or  secondary,  in  any  portion,  in 
the  mucosa  or  any  of  the  fibers  w^ithin  the  wall.  Primary  tuberculosis,  however,  is 
much  less  frequent  than  the  secondary  form,  which  is  usually  from  the  kidney  or  bladder, 
especially  the  kidney. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  in  any  portion  of  the  ureter,  but  more  frequently  near  the  extremities, 
in  which  instance  it  is  usually  secondary. 

Papillomata  may  be  congenital  or  acquired,  usually  acquired,  primary  or  secondary, 
single  or  multiple,  in  emy  portion,  but  most  frequently  at  the  extremities,  destroy  the 
lumen,  cause  the  formation  of  concretions,  strictures  or  general  destruction. 

Adenomata  may  be  congenital  or  acquired,  single  or  multiple,  not  pedunculated, 
in  any  portion,  but  most  frequently  at  the  extremities,  destroy  the  lumen,  cause  concretions, 
strictures  or  general  destruction. 

Fibromata  may  be  congenital  or  acquired,  single  or  multiple,  large  or  small, 
originate  in  the  muscular  tissue  of  the  ureter,  destroy  the  lumen,  and  cease  to  grow 
at  any  stage  of  development. 

Prolapsus  may  be  congenital  or  acquired,  acute  or  chronic,  into  the  bladder,  vagina, 
through  the  inguinal  or  femoral  ring. 

Concretions  may  form  within  or  enter  through  the  kidney  and  foreign  bodies 
through  the  peritoneal  cavity,  or  from  without  through  the  overlying  structures,  single 
or  multiple,  primary  or  secondary,  remain  or  pass  into  the  kidney,  bladder,  peritoneal, 
rectal,   vaginal,   uterine   cavity,   or   exterior   through   the   overlying   soft   structures. 

C})sts  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
parasitic  or  non-parasitic,  within  the  lumen,  muscular  coat  of  the  ureter,  rupture  into 
the  ureter,  kidney,  bladder,  vaginal,  uterine,  rectal,  peritoneal  or  intestinal  cavities,  through 
the  cutaneous   structures.    Fallopian  tubes   or  blood  vessels. 

Strictures  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
partial   or   complete,   vary   in   size,   shape,    and   in   any   portion. 

Fistulae  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
acute  or  chronic,  in  any  portion  of  the  ureter,  open  into  the  rectum,  vagina,  uterus. 
Fallopian  tubes,  peritoneal  or  alimentary  cavities,  or  through  the  overlying  soft  cutaneous 
tissues. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  single  or  multiple,  in  any  portion  or 
structure. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple,  in  any  portion,  especially 
the  muscularis,  slow  or  rapid  in  growth,  depending  upon  their  character  and  origin, 
the  result  of  accidental  or  induced  injury,  the  presence  of  concretions,  foreign  bodies, 
or  the  introduction  of  sounds,  and  of  myxomatous,  rhabdomyomatous,  or  other  varieties. 

Page  Seventy-Eight 


INJURIES. 

Ruptures  of  the  ureter  may  be  primary  or  secondary,  single  or  multiple,  partial 
or  complete,  longitudinal  or  circular,  lateral,  posterior  or  anterior,  into  the  peritoneal, 
uterine,  rectal  or  vaginal  cavities,  bladder,  surrounding  soft  structures,  or  kidney. 

Punctures  may  be  induced  from  within,  primary  or  secondary,  through  the  kidney 
or  bladder,  result  from  foreign  bodies,  concretions  or  introduction  of  sounds,  through 
the  peritoneal,  uterine,  rectal,  or  vaginal  cavities,  or  overlying  soft  structures,  and  in 
any   portion   of   the   ureteral   vv^all. 

Incisions  may  be  accidental  or  induced,  primary  or  secondary,  longitudinal,  or 
circular,  in  any  portion  of  the  ureteral  wall,  kidney,  bladder,  through  the  rectal,  vaginal, 
uterine,  or  peritoneal  cavities,  or  through  the  overlying  soft  structures  when  induced 
for  extra-peritoneal  ureterotomy. 

SYMPTOMS. 

Symptoms  pertaining  to  ureteral  conditions  herein  described  too  frequently  fail  in 
diagnosis,  especially  the  symptoms  of  pain  and  tenderness,  two  of  the  prominent  and 
constant  mdications,  because  the  sensitive  nerve  fibers  which  supply  the  ureter  are 
intimately  associated  with  those  of  the  kidney  and  bladder  and  their  adjacent  structures, 
thus  permitting  similar  impulses  due  to  nregular  conditions  within  them  to  be  transmitted 
through  their  nerve  fibers.  This  difficulty  obtains  with  the  existence  of  occlusion  which 
greatly  aggravates  all  others  and  becomes  the  most  prominent  factor. 

Pain  and  tenderness  in  the  ureter  predominate  in  local  manifestations  but  un- 
fortunately they  are  not  diagnostic,  especially  in  the  female,  but  when  they  persist  with 
general  disturbances  such  as  chill,  headache,  shock,  perspiration,  nausea  and  vomiting, 
sufficient  evidence  is  deduced  to  suspect  ureteral  conditions.  There  is  probably  no  part 
of  the  genito-urinary  tract  so  difficult  to  determine  symptomatically. 

Tenderness  may  indicate  many  conditions  or  none  at  all  because  its  degree 
varies  with  the  closeness  of  the  ureteral  lesion  to  the  bladder  which  increases  intensity. 
Bladder  symptoms  of  every  kind,  especially  those  due  to  irritation,  frequent  urination 
and  tenesmus  are  very  confounding.  The  lower  male  ureter  may  sometimes  be  palpated 
through  the  rectum,  but  the  point  of  lesion  is  not  then  made  certain. 


Page  .Sevoiit\-Nim 


CHAPTER  XII. 


KIDNEYS. 

(Male  and  Female.) 

ANATOMY. 


Fig.  46. 

IDNEYS  exceed  in  weight  that  of  the  other  urinary  tissues  com- 
bined, bmt  their  consideration  will  be  but  slightly  more  than  passing 
because  their  blood,  nerve  and  lymphatic  systems  are  independent 
of  the  other  portion  of  the  urinary  apparatus  and  far  distant  from 
the  pelvic  tissues. 

It  might  be  said  that  there  is  no  physiologic  relation  of  the 
kidneys  to  the  other  portion  of  the  urinary  tract,  except  that  of 
a  mechanical  character,  because  of  their  independent  relation. 

Blood  Vessels.  There  should  be  one  renal  artery  for  each 
kidney,  but  there  may  be  two  or  even  more  and  the  right  is  greater 
in  length. 

Vessels  supplying  the  kidney  do  not  anastomose  with  each 
other  as  each  end  artery  provides  for  a  particular  area  of  renal 
substance  (Piersol). 

The  nerves  of  the  kidney  are  derived  from  the  renal  plexus 


Page  Eighty 


formed  by  contributions  from  the  solar  and  aortic  j^lexuses  and  the  least  splanchnic 
nerve. 

The  plexus  accompanies  the  renal  artery  which  it  surrounds.  Within  the  latter  is 
formed  a  well-marked  perivascular  network  from  which  a  number  of  twigs  are  given  off 
to  supply  the  walls  of  the  pelvis  and  ureter,  while  the  majority  accompany  the  vessels  into 
the  kidney. 

Because  of  the  almost  total  absence  of  sensory  nerve  fibers  in  the  kidney  tissue,  very 
little  if  any  pain,  can  be  produced  within  from  any  cause  except  obstruction. 

I  he  lymphatics  of  the  l(idney)s  arise  from  two  networks,  one  superficial  and  the  other 
deep. 

The  superficial  network,  which  was  observed  by  Mascagni,  has  not  been  seen  by 
Ludwig  and  Kolliker.  The  new  classical  researches  of  Leichmann  and  Stahr,  however, 
leave  no  doubt  as  to  its  existence;  but  it  is  extremely  difficult  to  infect.  Immediately  under- 
neath the  capsule,  it  is  remarkable  for  the  tenuity  of  its  meshes. 

This  network  tw^o  systems  of  collecting  trunks  arise  which,  following  Sappy, 
we  may  divide  into  convergent  and  divergent.  The  convergent  empty  themselves  into  the 
collecting  trunks  of  the  deep  network  either  by  immediately  sinking  into  the  depth  of  the 
kidney,  or  by  running  under  the  capsule  only  to  join  the  deep  collecting  trunks  near  the 
hilum,  the  divergent  trunks  perforate  the  fibrous  capsule,  and  pass  into  the  network  which 
vv^e  shall  describe  further  on  when  dealing  with  the  fatty  capsule  of  the  kidney.  The  ar- 
rangement of  the  deep  network  eventually  gives  origin  to  large  collecting  trunks,  varying 
in  number  from  four  to  seven,  which  leave  the  kidney  at  the  hilum.  These  trunks  course 
around  the  artery  and  the  renal  vein.  They  are  usually  satellites  of  the  vein,  some  running 
on  into  anterior,  and  some  on  its  posterior  surface.  The  mode  of  termination  of  the  renal 
lymphatics  varies  on  the  two  sides.  On  the  right,  we  may  divide  the  vessels  into  anterior 
and  posterior.  The  anterior  trunks  run  in  front  of  the  renal  vein,  and  pass  downwards 
and  inwards  and  terminate  in  the  pre-venous  mass  of  right  juxta-aortic  glands.  They 
usually  terminate  in  the  group  of  the  above  mentioned  glands,  which  is  situated  on  the 
anterior  surface  of  the  vena  cava,  immediately  below  the  opening  of  the  renal  veins  into 
the  inferior  cava,  but  one  of  them  may  often  be  seen  to  end  in  a  gland  belonging  to  the 
same  group,  placed  much  lower  down,  close  to  the  bifurcation  of  the  aorta.  It  is  equally 
common  to  see  one  of  these  trunks  end  in  a  gland  of  the  pre-aortic  group.  The  posterior 
trunks  are  shorter  than  the  preceding,  and  are  placed  behind  the  vein  and  renal  arteries. 
They  terminate  in  two  or  three  large  glands  situated  behind  the  inferior  vena  cava,  in  front 
of  the  right  pillar  of  the  diaphragm.  These  glands  belong  to  the  retro-venous  group  of 
the  right  juxta-aortic  glands.  Their  different  vessels  pass  through  the  right  pillar  of  the 
diaphragm  traversing  it  through  the  same  orifice  as  the  great  splanchnic  nerve,  and  ter- 
minate in  the  thoracic  duct.  On  the  left,  the  collecting  trunks,  which  leave  the  kidneys 
at  the  hilum  terminate  in  four  or  five  glands  which  belong  to  the  juxta-aortic  group  of  the 
corresponding  aorta.  The  highest  of  these  glands  are  situated  in  front  of  the  left  pillar  of 
the  diaphragm,  through  which  their  efferent  vessels  pass  on  their  way  to  join  the  thoracic 
duct.  To  sum  up,  the  lymphatics  of  the  kidneys  end  principally  in  the  juxta-aortic  glands 
of  the  corresponding  side  and  accessorily  in  the  pre-aortic  glands.  In  any  case  it  is,  if 
not  absolutely  incorrect,  at  least  insufficient,  to  state  that  the  lymphatics  of  the  kidneys 
terminate  in  the  glands  placed  at  the  level  of  the  hilum  of  these  organs.  At  the  level 
of  the  hilum,  however,  we  may  meet  with  some  small  glandular  nodules,  but  by  reason  of 
their  contiguity  and  their  small  size,  they  should  be  regarded  as  belonging  to  that  variety 
of  gland  which  we  have  described  above  as  the  interrupting  glandular  nodule  (Schalt- 
driisen)  and  which  it  is  important  to  distinguish  from  the  regional  glands  which  are  much 
more  constant  in  their  presence  and  situation  (Stahr).  One  of  these  nodules  is,  however, 
distinguished  by  its  relative  frequency  and  by  its  fairly  constant  situation  beneath  the  right 
renal  vein,  in  the  angle  which  this  vessel  forms  with  the  inferior  vena  cava. 

The  fatt^  capsule  of  the  l(idne^  possesses  a  rich  lymphatic  network  which  has  been 
recently  described  by  Stahr.  The  efferents  of  this  network  end  in  the  same  glands  as  the 
collective  from  the  kidney  itself.      The  network  of  the   fatty  capsules  communicates,   as 

Page  Eighty-One 


we  have  seen,  with  the  lymphatics  of  the  kidney,  and  it  is  not  rare  to  find  during  the 
progress  of  epithehal  cancers  of  this  organ,  lines  of  new  growth  in  the  fatty  capsule. 

Lymphatics  of  the  Suprarenal  Capsule. — The  lymphatics  of  the  suprarenal  capsules, 
whose  mode  of  origin  will  be  studied  together  with  the  structures  of  these  organs,  end  in 
four  or  five  collecting  trunks,  which  emerge  at  the  same  point  as  the  large  centre^^  vein, 
and  terminate  in  the  juxta-aortic  glands  of  the  corresponding  side.  In  several  subjects, 
these  collecting  trunks  have  been  seen  to  perforate  the  pillars  of  the  diaphragm  and  end 
in  the  glands  placed  between  the  posterior  surface  of  these  pillars  and  the  vertebral  column. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

Diseases    |    Bf^/.^"- 

(^    Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  vary  in  shape,  size,  position,  number 
and  relation  to  other  structures.  One  or  both  may  be  absent,  which  last  event  would 
preclude  the  possibility  of  life  existing  after  birth  for  any  great  length  of  time,  but  the 
absence  of  one  does  not  prevent  the  continuance  of  life.  One  or  both  kidneys  may  be  ex- 
cessively lobulated,  large  or  small,  and  functionate  normally  in  amount  and  frequency. 

One  or  more  ureters  originate  in  the  same  kidney  and  the  proverbial  horseshoe  kidney, 
probably  exists  as  one  kidney. 


DISEASES. 

Benign.     Malignant. 

BENIGN. 

Nephritis  may  be  congenital  or  acquired,  primary  or  secondary,  unilateral  or  bilateral, 
acute  or  chronic,  local  or  general,  mild  or  severe. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  single  or  multiple,  more 
frequently  primary,  infected  simultaneously,  at  different  times,  or  one  alone  affected,  ap- 
pear in  any  portion,  disappear  spontaneously,  or  continue  to  its  destruction. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  in 
any  portion  of  one  or  both  simultaneously. 

Papillomata  may  be  congenital  or  acquired,  primary  or  secondary,  involve  any  por- 
tion or  all  of  one  or  both,  usually  both. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  unilateral  or 
bilateral,  single  or  multiple,  vary  in  size,  shape,  number  and  location. 

Lipomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location. 

Rhahdomyomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size, 
shape  and  location. 

Concretions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
remain  in  the  pelvis,  escape  into  the  cortex,  and  vary  in  size  (from  sand-like  grains,  to 
several  ounces) ,  shape  and  number. 

Fistulce  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary,  acute 
or  chronic,  originate  in  the  pelvis,  or  cortex,   appear  in  the  peritoneal  cavity,  upon  the 

Pag-e  Eighty-Two 


cutaneous  surface,  through  the  overlying  soft  structures,  pleural  cavity,  stomach,  intestinal 
tract,  rectum,  vagma,  bladder  or  Fallopian  tubes. 

Floating  l(idne^  may  be  congenital  or  acquired,  primary  or  secondary,  unilateral  or 
bilateral,  vary  in  degree;  it  is  usually  the  right  kidney  and  is  more  frequent  in  the  female. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  vary 
in  size,  shape,  in  any  portion,  the  pelvis  alone,  contain  blood,  pus,  serum,  occeisionally 
ecchinoccocci,  or  dermoid  material,  rupture  into  the  ureter,  peritoneal,  alimentary  or  pleural 
cavities.  Fallopian  tube,  uterus,  bladder,  rectum,  vagina  or  overlying  soft  structures. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  usually  primary,  and  single,  and  extend 
into  the  ureter  before  involving  the  surrounding  structures. 

Sarcomata  may  be  primary  or  secondary,  usually  primary,  seldom  multiple,  and 
extend  into  the  adjacent  soft  structures. 

INJURIES. 

Rupture  may  be  accidental  or  induced,  single  or  multiple,  primary  or  secondary,  from 
causes  without  or  within,  longitudinal  or  circular,  each  varying  in  extent,  partial  or  com- 
plete, into  the  pleural  or  peritoneal  cavity  or  overlying  soft  structures. 

Lacerations  may  be  accidental  or  induced,  primary  or  secondary,  single  or  multiple, 
complete  or  incomplete,  from  without  or  within,  in  any  direction,  involve  the  peritoneal, 
pleural,  or  alimentary  cavity  or  organs. 

Punctures  may  be  accidental  or  induced,  primary  or  secondary,  single  or  multiple, 
in  any  part  of  the  organ,  from  without  or  within,  through  the  peritoneal  cavity  or  the 
overlying  soft  structures,  the  result  of  instrumentation,  through  the  ureter  or  pelvis  of  the 
organ. 

Incisions  may  be  accidental  or  induced,  single  or  multiple,  primary  or  secondary, 
penetrating  or  non-penetrating,  from  without  or  within,  in  any  portion  of  the  organ,  longi- 
tudinal or  circular  and  involve  the  surrounding  tissues. 

SYMPTOMS. 

Symptoms  of  f(idney  irregularities  are  highly  intensified  because  of  its  size,  function 
and  intimate  association  with  organs  of  equal  importance,  namely  the  liver,  pancreas, 
stomach,  duodenum,  biliary  tract,  and  diaphragm,  each  of  which  is  supplied  with  numer- 
ous sensitive  nerve  fibers,  many  of  which  are  from  the  same  origin,  but  few  of  which  have 
even  slight  association  with  the  perineal  group. 

It  is  thus  observed  that  nephritic  symptoms  are  almost  independent  of  those  found 
in  the  uro-genital  tract  which  is  so  thoroughly  dominated  by  the  sympathetic  and  sacral 
plexuses.  For  this  reason  nephritic  symptomatology  cannot  be  placed  in  parallel  lines 
with  that  of  the  pelvic  organs  and  perineum.  But  as  all  kidney  secretions,  both  normal 
and  abnormal,  naturally  drain  through  the  ureters  into  the  bladder  to  make  their  exit 
through  the  urethra,  primary  symptoms  are  produced  within  these  organs  and  tissues  which 
cause  symptoms  of  all  combined. 

The  general  influence  of  renal  pathology  is  usually  severe,  and  local  manifestations, 
such  as  pain,  and  tenderness,  are  fair  indications  of  beginning  renal  disease,  but  when 
these  exceptions  are  increased  in  severity,  and  associated  with  chill,  headache,  shock,  per- 
spiration, nausea,  and  vomiting,  their  intensity  is  lost. 


rage  Eishty-Three 


CHAPTER  XIII. 


ERECTILE   BODY. 

(Penis  Clitoris.) 
ANATOMY. 


Fig.   47. — Male   urethra   cleft   dorsally    (Deaver). 

"^OV       Q/^  HE  ISCHIO-CAVERNOSUM,  also  named  erector  penis,  and 
w  ji\  if  Cy  erector    clitoris,    represents   the    lateral   portion   of   the   sphincter 

S^/^       RxV-y^  cloacae.     The  two  muscles  occupy  the  lateral  parts  of  the  super- 

ficial perineal  interspace,  each  arising  from  the  base  of  the  tu- 
berosity of  the  ischium  enclosing  the  base  of  the  crus  penis- 
clitoris  as  in  a  sheath  and  passing  forward  to  be  inserted  into  the 
corpus  cavernosum.  The  muscle  in  the  female  differs  from  that 
in  the  male  only  in  size. 

Its  function  is  to  compress  the  corpus  cavernosum  and  thus 
assist  in  producing  or  maintaining  erection  of  the  penis  or  clitoris. 
The  artery  of  the  corpus  cavernosum  (profunda  penis  in 
the  male,  profunda  clitoris  in  the  female)  is  usually  the  larger 
of  the  two  terminal  branches.  Immediately  after  its  origin  it 
enters  the  crus  penis  and  runs  forward  in  che  corpus  cavernosum 
which  it  supplies. 
Bulbo  Cavernosum  differs  in  its  relations  in  the  two  sexes,  being  in  the  male  the  ac- 


Page  Eig'hty-Four 


celerator  urinae,  the  two  muscles  of  the  opposite  sides  being  united  in  a  median  fibrous 
raphe  which  extends  forward  from  the  central  tendon  of  the  perineum  over  the  bulbo  and 
corpus  spongiosum.  Arising  from  this  raphe  the  fibers  are  directed  laterally  and  forward 
over  the  bulb  and  corpus  spongiosum  to  become  inserted  into  the  under  surface  of  the 
inferior  layer  of  the  uro-genital  trigone  and  into  the  fibrous  sheath  of  the  corpus  caver- 
nosum,  some  of  the  more  anterior  fibers  being  continued  dorsally  to  be  inserted  mto  the 
fascia  covering  the  dorsum  of  the  penis  and  forming  what  has  been  termed  the  muscle  of 
Hauston,  or  compressor  venae  dorsalis  penis,  and  sphincter  vaginae  in  the  female. 

The  arler})  to  the  bulb,  a  branch  of  which  is  usually  of  relative  large  size,  is  given 
off  between  the  layers  of  the  triangular  ligament.  It  runs  transversely  inwards  along  the 
posterior  border  of  the  compressor  urethra,  and  then  turning  forwards  a  short  distance  from 
the  outer  side  of  the  urethra,  pierces  the  anterior  layer  of  the  triangular  ligament  amd  enters 
the  substance  of  the  bulb.  It  passes  onwards  in  the  corpus  spongiosum  to  the  glans  where 
it  anastomoses  with  its  fellow  and  with  the  dorsal  arteries  of  the  penis.  It  supplies  the 
compressor  urethra  muscle,  Cowper's  gland,  the  corpus  spongiosum,  and  the  penile  part  of 
the  urethra.     In  the  female  this  artery  supplies  the  bulb  of  the  vestibule. 

The  dorsal  artery  of  the  penis  passes  forward  between  the  layers  of  the  suspensory 
ligament,  and  runs  along  the  dorsal  nerve  immediately  to  its  outer  side,  whilst  it  is  sepa- 
rated from  its  fellow  of  the  opposite  side  by  the  median  deep  dorsal  vein.  It  supplies 
the  superficial  tissues  on  the  dorsal  aspect  of  the  penis,  sends  branches  to  the  corpus 
cavernosum,  and  its  terminal  branches  enter  the  glans  penis,  where  they  anastomose  with 
the  arteries  to  the  bulb.     It  also  anastomoses  with  the  external  pudic  branches  of  the  femoral. 

The  nerve  supply  of  the  bulbo  cavernosus  is  from  the  perineal  branches  of  the  pudic 
nerve  and  its  purpose  to  compress  the  bulb  and  corpus  spongiosum  and  to  assist  in  ex- 
pelling the  fluid  contained  in  the  urethra.  The  muscular  fibers  which  pass  to  the  dorsum 
of  the  penis  or  clitoris  may  aid  slightly  in  their  erection  either  directly  or  by  compressing 
the  dorsal  vein. 

The  integument  of  the  root  of  the  penis  is  supplied  by  the  ilio-inguinal  and  inferior 
pudendal  nerves  and  the  body  and  prepuce  by  the  branches  of  the  dorsal  nerves.  Branches 
of  the  pudic  supply  the  bulbus  urethra  and  mucous  membrane  of  the  urethra  and  each  corpus 
cavernosus  by  a  deep  branch  from  the  dorsal  nerve. 

Perineal  branches  of  the  pudic,  ilio  inguinal,  and  sympathetic  nerves  from  the  hypo- 
gastric plexus  control  the  erection  of  the  penis  and  clitoris. 

Lymphatics  of  the  Clans  Penis. — The  collecting  trunks  of  the  glands  arise  from  a 
fine  network  which  partly  drains  the  network  of  the  prepuce  and  the  balanitic  portion  of 
the  urethra.  These  collecting  trunks  are  two  or  three  in  number.  The  exact  point  of 
origin  is  at  the  frenum,  since  a  series  of  finer  collecting  trunks  drain  and  converge  at  this 
point.  Two  or  three  trunks  which  drain  the  mucous  membrane  of  the  urethra  also  empty 
into  the  main  collecting  trunks.  The  course  of  the  main  collecting  trunks  is  around  the 
corona  of  the  glands  and  from  two  to  four  collecting  trunks  and  anastomose  with  those 
of  the  opposite  side,  which  run  parallel  with  the  dorsal  vein  of  the  penis,  and  terminate  in 
the  pre-symphysical  at  the  penile  root. 

The  cutaneous  lymphatics  of  the  penis  are  divided  into  two  sets  the  lymphatics  of 
the  sheath,  and  the  lymphatics  of  the  prepuce. 

Lymphatics  of  the  sheath  have  four  or  five  collecting  trunks.  They  differ  in  length. 
Those  most  anterior  are  longer.  These  collecting  trunks  take  their  origin  from  the  dense 
lymphatic  network  of  the  prepuce.  The  collecting  trunks  pass  around  the  lateral  surface 
of  the  penis  to  the  dorsal  surface;  after  which  they  pass  to  the  penile  root,  where  they 
make  a  sharp  turn  outwards  to  the  inguinal  glands. 

Lymphatics  of  the  prepuce  originate  from  the  fine  network  in  the  plicature  of  the 
skin  of  the  preputial  fold.  They  are  also  continuous  from  the  lymphatics  of  the  glands  in 
the  balanitic  portion.  The  collecting  trunks  vary  in  number  from,  one  to  two,  to  a  mul- 
tiplicity of  collecting  tmnks. 

Their  course  is  along  the  dorsum  of  the  penis,  near  the  superficial  dorsal  vein.  When 
more  than  one  trunk  exists  they  give  off  anastomosing  branches  along  their  course,  at  the 

Page  Eishty-Five 


penile  root.  If  only  one  trunk  is  present  it  may  divide  into  two  trunks,  which  are  equal  in 
size  or  it  may  continue  without  division  to  its  limitation  which  is  an  inguinal  gland.  When 
several  trunks  exist  they  form  two  at  the  penile  root.  They  usually  terminate  in  the  supero- 
internal  group.  Yet,  however,  they  may  also  terminate  in  other  glandular  groups  of  this 
region.     The  collecting  trunks  are  located  just  beneath  the  integument. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 
Male  Erectile  BodV- 

Anomalies. 

D"l     Benign. 
iseases    ^    ^;,  ,•* 

J     Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  of  the  erectile  bodies  may  be  congenital  or  acquired,  primary  or  secondary, 
vary  in  position  and  relation  to  other  tissues,  the  blood,  nerve,  and  lymph  supply  more  or 
less  than  normal  and  any  one  or  more  of  its  structures,  wanting  in  part  or  their  entirety. 

Shape  may  be  regular  or  irregular,  smooth  or  nodulated,  curve  upward,  down- 
ward, to  either  side,  taper  excessively  from  the  proximal  or  distal  end. 

Blind  Pouches  may  be  congenital  or  acquired,  single  or  multiple,  vary  in  size,  shape 
and  location  and  contain  mucus  or  serum. 

Shape  may  be  excessively  long  or  short,  diameter  vary  greatly  from  end  to  end,  single 
or  multiple,  position  to  the  right  or  left  of  the  median  line,  high  or  low,  concealed  in  part 
or  its  entirety,  within  the  scrotum,  perineum,  groin  or  upper  thigh. 


DISEASES. 

Benign.     Malignant. 
BENIGN. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  due  to  trauma  or  infection  in  any  tissue  or  portion  of  the  erectile  body, 
continue,  cease  to  grow  or  disappear  spontaneously. 

Syphilis  may  be  congenital  or  acquired,  acute  or  chronic,  primary  or  seconda^y^  in 
the  form  of  chancre,  chancroid,  gumma,  single  or  multiple,  vary  in  size,  shape  and  location. 

Tuberculosis  may  be  acute  or  chronic,  primary  or  secondary,  single  or  multiple,  vary 
in  size,  shape  or  location  in  any  tissue. 

Fibromata  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
in  any  portion  of  the  gland,  originate  in  any  tissue  and  extend  into  the  adjacent  structures. 

Lipomata  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
round,  oblong,  smooth  or  lobulated  in  any  of  the  fatty  structures,  vary  in  size,  remain 
dormant,  increase  or  diminish  in  size  or  disappear  spontaneously. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  shape,  location,  usually  without  pedicle,  and  in  any  tissue. 

Concretions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
soft  or  hard,  usually  between  the  gleind  and  prepuce,  vary  in  size,  shape,  and  number  in 

the  body. 

Bon^  deposits  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, hard  or  soft,  vary  in  shape,  size  and  location,  involve  a  part  or  all  of  the  organ,  the 
walrus,  raccoon,  many  monkeys,  dog  and  many  members  of  the  negro  race  being  examples. 

Page   Eighty-Six 


Horn^  g;olP//is  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, vary  in  size,  shape  and  location,  continue  or  cease  to  grow,  or  disappear  spontaneously. 

Lymphangitis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
mild  or  severe. 

Lupus  may  be  primary  or  secondary,  vary  in  shape,  size  and  position. 

Gangrene  may  be  mild  or  severe,  in  any  portion,  with  partial  or  complete  loss  of  the 
organ,  always  acute. 

Elephantiasis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
from  slight  to  enormous  in  size,  usually  general. 

Cysts  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary,  con- 
lain  blood,  pus,  mucus  or  serum,  originate  in  any  of  the  structures,  especially  externally, 
rupture  into  the  rectum,  urethra,  bladder,  perineum,  scrotum,  vagina,  uterus  or  peritoneal 
cavity. 

Fistulae  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
extend  from  the  urethral  canal  through  the  cutaneous  structures,  connect  with  the  rectum, 
vagina,  bladder,  peritoneal  or  uterine  cavities  or  through  the  perineal  body,  several  chan- 
nels existing  at  the  same  time. 

Phimosis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
partial  or  complete,  with  or  without  adhesions. 

Paraphimosis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  usually  primary,  and  single,  in  any 
tissue,  especially  the  prepuce  corona  or  distal  end  of  the  gland. 

Sarcomata  may  be  primary  or  secondary,  in  any  tissue  amid  portion  of  the  glauid. 

INJURIES. 

Ruptures,  lacerations,  punctures,  incisions  and  contusions  may  be  the  result  of  acci- 
dent or  design,  penetrating  or  non-pentrating,  primary  or  secondary,  smooth  or  irregular, 
longitudinal  or  circular,  in  any  portion  of  the  body. 

Fractures  may  be  congenital  or  acquired,  usually  acquired,  single  or  multiple,  by 
accident  or  design,  complete  or  incomplete,  in  any  portion  of  the  body. 

Dislocations  may  be  congenital  or  acquired,  forward,  backward  or  to  either  side. 

SYMPTOMS. 

Symptoms  pertaining  to  the  erectile  body  in  the  male  and  female  are  very  similar 
physiologically,  tenderness,  pain  and  general  nervous  disturbances  being  most  prominent. 

Pain  of  any  degree  may  be  acute  or  chronic,  primary  or  secondary,  and  sometimes 
due  to  conditions  far  distant  to  the  erectile  body.  Adhesions  and  furuncles  about  the 
clitoris  are  not  uncommon  causes,  but  any  disease  or  irritation  may  cause  erection  of  this 
body,  or  it  may  be  purely  psychical,  \vith  or  without  frequent  desire  to  urinate  and  the 
amount  of  urine  increased. 

Cardio-vascular  disturbances  resulting  from  abnormal  conditions  of  the  male  repro- 
ductive organs  are  more  or  less  in  evidence,  especially  with  infections  and  advanced  pros- 
tatic conditions.  Those  affecting  the  erectile  body,  testes,  spermatic  ducts  and  scrotum 
being  not  so  highly  manifested. 

Vascular  symptoms  of  the  male  erectile  body  are  induced  by  severe  and  prolonged 
pain,  the  pulse-rate  varying  from  slow  to  rapid  as  the  result  of  these  causes  but  the  rate 
and  quality  may  change  from  time  to  time  without  any  perceptible  irregularity  in  the  organ. 

Urinary  disturbances  are  always  present  with  any  pathology  or  trauma  that  may 
exist  in  the  erectile  body  of  the  male.  The  amount  of  urine  may  be  greatly  increased'  or 
diminished  and  contain  blood,  pus,  concretions  or  necrotic  tissue  and  cause  severe  burning 
or  tenesmus,  or  it  may  escape  through  one  or  more  of  the  many  forms  of  artificial  openings. 

Page  Eighty-Seven 


CHAPTER  XIV. 


PROSTATE  GLAND. 
ANATOMY. 


open  into  the  prostatic 


Fig.  48. 

HE  PROSTATE  GLAND  normally  is  composed  of  two  lateral 
and  a  m.iddle  lobe,  the  three  combined  being  about  the  size  and 
shape  of  a  large  horse  chestnut,  in  the  adult,  and  weighs  about 
'/2  ounce.  The  middle  lobe  which  is  about  the  size  of  a  pea  is 
frequently  absent  while  the  lateral  lobes  vary  in  shape  and  size, 
one  of  which  may  be  also  absent.  The  three  lobes  are  enclosed 
m  a  thin,  firm,  fibrous,  capsule  and  the  urethra  and  seminal  ducts 
pass  through  the  gland  but  often  vary  in  their  course.  The  two 
small  yellow  bodies  about  the  size  of  a  pea  which  lie  beneath  the 
anterior  part  of  the  membranous  urethra  close  behind  the  bulb 
and  are  enclosed  in  the  transverse  fibers  of  the  compressor  urethra 
muscle,  were  discovered  by  Cowper  for  whom  they  are  named. 
The  prostate  gland  is  composed  of  many  fcllicles  and  muscular 
fibers  in  such  a  number  as  to  form  fifteen  to  twenty  channels 
designated  as  secretary  ducts  lined  with  columnar  epithelian  and 
urethra. 


Page  Eig-hty-Bight 


The  prostatic  muscle  is  supported  upon  the  anterior  wall  of  the  bladder  by  fibers  of 
the  levator  ani,  which  are  also  called  levators  of  the  prostate  on  the  sides. 

Leuckhart  states  that  in  women  there  exists  a  true  rudimentary  prostate,  consisting 
principally  of  mucous  follicles  and  situated  between  the  beginning  of  the  urethra  and  the 
reflection  of  the  vagina.  Flodgson  also  states  that  Virchow  admitted  the  existence  of  this 
body,  found  at  the  neck  of  the  bladder,  especially  in  old  women. 

Most  observers  have  held  that  the  glandular  portion  of  the  prostate  originates  from 
the  urethra  and  the  stroma  of  the  organ  develops  from  a  thickening  of  the  genital  chord, 
but  Griffiths  and  Richardson  who  have  made  a  detailed  study  of  this  gland  say  that  no 
part  is  developed  from  the  genital  chord. 

The  blood  suppl];  is  from  the  middle  hemorrhoidal,  inferior  vesical  and  internal  pudic 
artery  while  a  large  venous  plexus  surrounds  it.  Into  this  plexus  veins  of  the  penis  open 
and  communicate  with  the  vesical  plexus  and  drain  into  the  iliac  veins.  These  veins  which 
become  larger  with  advanced  age,  besides  draining  the  dorsal  veins,  also  drain  those  of  the 


Fig.    49. — Bladder,    prostate,    seminal    vesicles,    vasa    deferentia     (Deaver). 

bladder,  seminal  vesicles  and  the  rectum,  and  are  continued  as  the  prostatic  vesical  plexus, 
tributary  to  internal  iliac  veins. 

Nerve  supply  is  from  the  hypogastric  plexus  in  the  form  of  sympathetic  fibers  asso- 
ciated with  small  ganglia  along  their  course.  Pacinian  corpuscles  are  said  to  be  con- 
nected with  the  sensory  fibers  (Piersol). 

Lymphatics  of  the  prostate  arise  by  fine  capillaries  arranged  in  the  form  of  a  net- 
work around  each  glandular  acinus.  From  these  periacinous  networks,  run  larger  ves- 
sels which  pass  towards  the  periphery  of  the  gland,  and  form  at  its  surface  a  second 
network,  the  peri-prostatic  network,  from  which  the  collectors  start.  The  latter  which 
are  symmetrically  arranged  on  each  side  of  the  gland,  may  run  in  four  different  directions. 

A  primary  trunk  starts  from  the  posterior  surface  of  the  prostate,  and  runs  on  to 
the  bladder  in  the  triangle  between  the  vasa  deferentia.  It  ascends  as  far  as  the  middle 
part  of  the  postero-superior  surface  of  the  bladder,  where  it  curves  sharply  outward,  across 


Page  Eighty-Nine 


the  hypogastric  artery,  and  terminates  in  the  middle  gland  of  the  middle  chain  of  the 
external  iliac  group.  In  its  retro-vesical  course,  this  trunk  describes  numerous  curves;  it 
may  pass  through  some  small  interrupting  glandular  nodules  (Schaltdriisen)  close  to  the 
spot  where  it  crosses  the  hypogastric  artery.  This  ascending  channel  frequently  consists 
of  two  trunks  which  then  terminate  in  the  middle  and  superior  glands  of  the  middle  chain. 

A  second  collector  arising  like  the  preceding  from  the  posterior  surface  of  the  pros- 
tate, accompanies  the  prostatic  artery.  Like  the  latter,  it  runs  upwards,  outwards  and 
backwards,  and  terminates  in  one  of  the  middle  glands  of  the  hypogastric  group.  In 
the  neighborhood  of  the  prostatic  origin  of  this  trunk,  two  or  three  small  glandular  nodules 
are  almost  constantly  found. 

Ttpo  or  three  other  collecting  trunks  also  start  from  the  posterior  surface  of  the 
gland,  and  run  at  first  downwards,  and  then  backwards.  They  enter  the  sacro-recto- 
genital  aponeurosis,  cross  the  lateral  surface  of  the  rectum,  and  then  ascend  on  the  an- 
terior surface  of  the  sacrum.  They  do  not  all  terminate  in  the  same  manner.  The 
shorter  and  more  external  end  in  the  lateral  sacral  glands,  which  as  we  have  already  seen, 
are  usually  situated  internal  to  the  second  sacral  foramen,  the  longer  and  more  internal 
pass  as  far  as  the  promontory  to  terminate  in  the  glands  situated  there. 

Finally,  from  the  anterior  surface  of  the  prostate  may  be  seen  a  descending  trunk 
which  runs  towards  the  pelvic  floor,  where  it  unites  with  the  vessels  coming  from  the 
membranous  portion  of  the  urethra.  In  company  with  the  latter,  it  embraces  the  artery 
of  the  corpus  spongiosum,  and  then  runs  with  the  internal  pudic ;  it  finally  terminates  in  a 
gland  of  the  hypogastric  group,  situated  on  the  intrapelvic  portion  of  the  trunk  of  the 
internal  pudic  artery.  The  descending  prostatic  channel,  which  was  observed  in  the  dog 
by  Walker,  has  also  been  found  in  man  by  Marcille  (three  times  in  fifteen  subjects). 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

P^.  /   Benign. 

Uiseases.  S    iv/r  r         . 
^   Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
vary  in  shape,  number,  position,  size  and  relation  to  other  tissues,  or  none  at  all  but  doubt 
exists  about  the  total  absence  of  prostatic  tissue. 


DISEASES. 

Benign.     Malignant. 

BENIGN. 

Adenomata  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
usually  primary,  in  any  portion  of  one  or  more  glands,  vary  in  size,  shape,  location,  cease 
to  grow,  continue  to  increase  in  size,  disappear  spontaneously,  undergo  cystic  or  malig- 
nant chcinges. 

Papillomata  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
usually  primary,  in  any  portion  of  one  or  more  glands,  vary  in  size,  shape,  location,  cease 

Pag-e  Ninety 


to  grow,  continue  to  increase  in  size  or  disappear  spontaneously,  and  are  usually  pedun- 
culated when  upon  the  surface. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  vary  in  size,  shape  and 
location  in  any  tissue. 

SypInUs  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  vary 
in  size,  shape,  location,  in  any  tissue  in  the  form  of  gumma. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  contain  blood,  pus,  mucus,  serum,  seminal  fluid,  dermoid  material,  eccliinococci, 
rupture  into  the  bladder,  urethra,  rectum,  perineum,  peritoneal  cavity,  or  through  the  over- 
lying soft  structures  anywhere  upon  the  surface  about  the  pelvis  or  upper  thigh. 

Concretions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
large  or  small,  soft  or  hard,  escape  from  the  bladder  into  the  prostate,  rupture  to  pass  into 
the  rectum,  urethra,  perineum  or  peritoneal  cavity. 

Foreign  bodies  may  enter  the  gland  through  the  bladder,  rectal  wall,  urethra,  peri- 
neum, skin,  the  overlying  soft  structures  become  encysted  or  pass  into  the  rectum,  urethra, 
bladder,  perineum,  peritoneal  cavity  or  overlying  soft  structures. 

Fisiulae  may  be  congenital  or  acquired,  single  or  multiple,  acute  or  chronic,  open 
into  the  bladder,  rectum,  perineum,  urethra,  peritoneal  cavity  or  soft  structures  and  skin, 
vary  in  size,  shape,  and  number. 

MALIGNANT. 

Carcinomaia  may  be  primary  or  secondary,  usually  primary,  single,  or  multiple  in 
one  or  all  of  the  three  lobes  and  involves  by  extension  one  or  all  of  the  surrounding  tissues. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiplle,  almost  invariably 
single,  usually  originate  in  the  body  of  the  gland,  and  extends  into  the  surrounding  structures. 

INJURIES. 

Ruptures,  punctures,  incisions,  may  be  primary  or  secondary,  in  the  gland  through 
the  urethra,  bladder,  rectum,  perineum  or  peritoneal  cavity,  by  accident  or  design,  and 
involve  a  part  or  all  of  the  adjacent  soft  structures. 

SYMPTOMS. 

S]^mpioms,  prostatic  in  character,  are  pronounced  when  extreme  irregularities  are 
present  especially  when  the  flow  of  urine  is  obstructed. 

They  are  often  difficult  to  define  because  the  gland  is  concealed  within  a  capsule  and 
because  of  the  relation  of  the  capsule  to  other  important  structures  richly  supplied  ^vith  nerve 
fibers,  blood  vessels  and  lymphatics.  The  earlier  symptoms  are  especially  difficult  to  de- 
fine but  those  advanced  are  more  definite. 

Pain  becomes  more  severe  with  advanced  conditions  but  pain  in  the  prostate  may 
be  reflected  from  sources  far  distant  from  the  gland. 

The  pain  may  be  dull  and  heavy,  of  a  bearing  down  character,  at  times  resembling 
the  sensation  of  burning  with  more  or  less  urethral  and  rectal  tenesmus.  There  is  always 
local  tenderness  and  when  far  advanced  it  may  be  general  throughout  the  pelvis  asso- 
ciated with  general  irritability,  emaciation  and  exhaustion.  Pain  may  be  suprapubic,  in 
the  lumbar  region,  at  times  of  urination  or  defecation,  retention,  tenderness,  frequent  urina- 
tion, all  of  which  resemble  those  pertaining  to  stone  in  the  bladder. 

All  of  these  symptoms  may  indicate  conditions  other  than  prostatic. 


Page  Ninety-One 


CHAPTER  XV. 


COWPER'S  GLANDS. 


it/Ov^T^i  - 


Fig.    50.      (Ayers.) 

OWPER'S  GLANDS  are  situated  between  the  two  layers  of  the 
triangular  ligament,  anteriorly  to  the  prostate  gland.  Normally 
there  are  two  in  number,  but  there  may  be  only  one.  Discovered 
1696. 

They  are  ovoid  in  shape  just  beneath  the  membraneous  por- 
tion of  the  urethra,  close  to  the  mid-line  on  each  side.  They 
are  the  size  of  an  ordinary  pea,  irregular  and  somewhat  knobbed 
in  shape.  They  are  of  a  pinkish  hue,  firm  imbedded  in  the 
fibers  of  the  compressor  urethra  muscle.  The  ducts  are  1 .5  mm. 
in  diameter,  3.4  mm.  in  length.  They  open  by  small  slit-like 
orifices  on  the  lower  wall  of  the  bulbus  urethra  near  the  mid  line. 
The  ducts  sometimes  open  into  the  urethra  by  a  common  orifice. 
They  are  homologous  with  the  Bartholin  glands  in. the  female 
and  are  accessory  organs. 

TliQ  blood  supply  are  twigs  from  the  arteries  of  the  bulk, 
and  the  veins  are  tributary  to  those  returning  the  blood  from  the  bulbus  spongiosum,  which 
empty  into  the  internal  pudic. 

The  lymphatic  are  afferents  to  the  internal  iliac  lymph  nodes. 

Besides  anomalies    (which  is  probably  of  little  importance),  the  various  forms  of 
disease   and   growths   may  be   found  involving  these   glands.      If   so,   they  must  play   a 


Page  Ninety-Two 


prominent   role   in   symptomatology,   especially   mflammation   due  to   gonorrhea,   the  most 
common  form  of  disease. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

Diseases    |    P,^"'^"- 

l^    Malirnant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location  or  entirely  absent. 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Inflammation  (Cowperitis)  may  be  primary  or  secondary,  acute  or  chronic,  unilateral 
or  bilateral,  usually  the  result  of  gonorrheal  infection,  more  frequent  than  suspected,  and 
of  more  importance  as  an  etiologic  factor  than  accredited. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location. 

Papillomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size, 
shape,  number  and  location. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  local  or  general,  cease 
to  grow  or  disappear  spontaneously. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
become  arrested,  continue  to  destruction  or  disappear  spontaneously. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  vary  in  size,  shape  and  rupture  mto  the  urethra  (its  natural  course),  rectum, 
bladder,  perineum  or  peritoneal  cavity. 

Fisiulae  may  be  primary  or  secondary,  usually  acquired,  single  or  multiple,  vary  in 
size,  shape  and  location,  open  into  the  urethra,  bladder,  prostate,  rectum,  perineum  or 
peritoneal  cavity. 

MALIGNANT. 

Carcinoma  may  be  primary  or  secondary,  single  or  multiple,  vary  in  size,  shape  and 
location. 

Sarcomata  may  be  primary  or  secondary,  usually  primary  and  single,  vary  in  size, 
shape  and  location. 

INJURIES. 

Lacerations  and  contusions  may  be  by  accident  or  design,  primary  or  secondary,  single 
or  multiple,  through  the  urethra,  or  rectum  and  usually  caused  by  the  introduction  of  sounds. 

SYMPTOMS. 

S})mptoms  of  conditions  within  Cowper's  gland  have  not  been  given  due  considera- 
tion because  of  their  size  and  inaccessibility.  Their  exposure  to  infections  is  equally  as 
great  if  not  greater  than  the  spermatic  ducts  beyond  them,  but  their  concealment  in  the 
deeper  structures  prevents  any  definite  conclusions  whatever  bemg  devolved  from  symptoms 
which  they  produce.  They  are  no  doubt  similar  to  those  resulting  from  genito-urinary  and 
rectal  conditions  in  general,  but  especially  of  the  prostate  and  posterior  urethra. 

It  is  therefore  impossible  to  ascribe  to  Cowper's  glands  at  this  time,  any  definite 
symptomatology. 

Pase  Ninety-Three 


CHAPTER  XVI. 


TESTICLES. 
ANATOMY. 


held  together  by  delic 


Fig.    51.      (Deaver.) 

HE  TESTES  are  two  glandular  organs  which  secrete  the  semen. 
They  are  slightly  compressed  ellipsoidal  bodies,  suspended  in 
the  scrotum  by  the  spermatic  cord,  the  left  lower  than  the  right. 
They  each  measure  about  4j/2  cm.  in  length,  2  J/2  cm.  in  width 
and  2  cm.  in  thickness. 

In  early  foetal  life  they  are  in  the  abdomen,  post-peritoneal. 
Before  birth  they  descend  into  the  scrotum  through  the  inguinal 
canal,  carrying  along  the  various  layers,  nerves,  blood  vessels,  etc. 

The  framework  proper  consists  of  a  stout  capsule,  the  tunica 
albugima,  which  gives  form  to  the  organ  and  protects  the  sub- 
jacent glandular  tissue. 

From  the  greatly  thickened  posterior  portion  of  the  tunica 

albuginea,  numerous  septa  arise  which  pass  forward  and  divide 

the  organ  into  separate  compartments  (or  lobules)  each  of  which 

contains  from  one  to  three  greatly  convoluted  seminiferous  tubules 

ate  vascular,  intertubular  connective  tissue. 


Pas-e    Ninety- Four 


Blood  supply  is  from  the  spermalic  artery  which  is  a  branch  of  the  aorta.  It  is  a 
long  slender  vessel  entering  upon  the  posterior  border  of  the  testis,  where  it  imnnediately 
breaks  up  into  many  branches  which  enter  the  diastinum  testis  to  become  distributed  along 
the  septa  and  on  the  deep  surface  of  the  tunica  albuginea. 

The  veins  issuing  from  the  posterior  border  of  the  testis,  form  a  dense  plexus  called 
the  plexus  pampiniformis,  which  finally  pours  its  blood  through  the  spermatic  vein,  on  the 
right  side,  into  the  vena  cava,  on  the  left  side  the  spermatic  vein  joins  the  left  renal  vein. 
(Cunningham.) 

Nerve  supply  for  the  testis  accompanying  spermatic  artery  and  is  derived  through 
the  aortic  and  renal  plexuses  from  the  tenth  thoracic  segment  of  the  spinal  cord.  The 
afferent  fibers  from  the  epididymis  appear  to  reach  the  spinal  cord  through  the  posterior 
roots  of  the  eleventh  and  twelfth  thoracic  and  first  lumbar  nerves.  The  arteries  and  nerves 
of  the  testis  communicate  with  those  on  the  lower  part  of  the  vas  deferens,  namely,  with 
the  artery  of  the  vas  and  with  twigs  from  the  hypogastric  plexus. 

Gerald  Maichant  laid  great  stress  upon  the  sinuosities  of  these  collecting  trunks.  They 
are  caused  by  the  penis  alternating  between  the  erect  and  flaccid  state. 

Lymphatics  of  the  testicles  anastomose  with  those  of  the  epididymis,  and  those  of 
the  visceral  layer  of  the  tunica  vaginalis.  They  pass  along  the  spermatic  cord,  in  intimate 
relation  with  its  blood  vessels.  The  former  are  more  superficial  than  the  latter.  In  the 
lumbar  region  the  lymphatics  leave  the  spermatic  cord  and  vessels,  and  as  they  do  so 
they  make  a  regular  curve  or  an  acute  angle.  On  the  right  side  they  terminate  in  the 
juxta-aortic  glands.  One  or  two  afferent  trunks  are  received  by  the  lowest  gland,  which  is 
located  just  above  the  bifurcation  of  the  inferior  vena  cava.  One  or  two  of  these  lymphatics 
also  terminate  in  one-third  of  the  cases,  in  the  pre-aortic  glands. 

On  the  left  side  these  lymphatics  terminate  in  three  or  four  of  the  juxta-aortic  glands. 
The  latter  are  arranged  in  rows  below  the  renal  vessels.  Sometimes,  however,  some  of 
these  lymphatics  also  terminate  in  the  pre-aortic  glands. 

The  terminals  of  the  left  testicle  are  on  a  higher  level  than  those  on  the  right,  except 
in  one-third  of  the  cases,  when  they  are  on  the  same  level. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

Diseases    ^     P,^";^"- 

(     Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
vary  in  size,  location,  shape  and  structure,  partially  or  completely  concealed  within  the 
abdominal  wall,  between  the  outer  inguinal  ring  and  scrotum,  or  one  or  both  entirely  wanting. 


DISEASES. 

Benign.     Malignant. 
BENIGN. 


Orchitis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
local  or  general,  unilateral  or  bilateral. 

Tuberculosis  may  be  primary  or  secondary,  single  or  multiple,  acute  or  chronic,  in 
one  or  both  simultaneously,  in  any  of  their  tissues,  especially  in  the  earlier  statues,  in  the 


Payo  Xinet\-Fi\-( 


primary  form,  confined  to  the  gland  or  glands,  or  extend  into  their  surrounding  soft 
structures. 

Sy^philis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  in- 
volve one  or  both  glands,  continue  in  its  destruction,  remain  stationary,  disappear  spon- 
taneously or  involve  the  overlying  soft  structures.  ^^ 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape,  and  involve  either  one  or  both  glands,  in  any  tissue. 

Lipomaia  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape,  location  and  extend  into  the  surrounding  structures. 

Retraction  may  be  congenital  or  acquired,  primary  or  secondary,  partial  or  com- 
plete, temporary  or  permanent,  unilateral  or  bilateral. 

Hemorrhagic  infarct  may  be  congenital  or  acquired,  primary  or  secondary,  usually 
acute,  vary  m  size,  location  and  seventy. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  in  one  or  both  glands,  originate  in  the  cortex,  the  ducts,  connect  with  the 
peritoneal  cavity  into  w^hich  they  may  discharge,  rupture  through  the  external  and  cutaneous 
structures,  seldom  if  ever  into  the  urethra,  occasionally  into  the  rectum,  more  frequently 
into  the  perineum,  contain  blood,  pus,  serum,  dermoid  material,  or  echinococci,  one  or  more 
simultaneously. 

Fistulae  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  con- 
nect with  the  peritoneal  cavity,  urethra,  rectum  or  perineum,  one  or  all,  at  the  same  time, 
become  closed  spontaneously,  remain  indefinitely,  vary  in  size  or  course  or  rupture  through 
the  soft  structures. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  usually  epitheliomatous  and  vary  in 
size,  shape  and  number. 

Sarcomata  may  be  primary  or  secondary,  vary  in  location,  and  in  any  tissue. 

INJURIES. 

Foreign  bodies  invariably  enter  the  gland  through  the  overlying  soft  structures.  They 
may  be  single  or  multiple,  vary  in  size,  location  and  character,  become  encysted,  remain 
permanently,  escape  into  the  scrotum  where  they  may  remain,  or  through  which  they 
may  afterward  escape. 

Ruptures,  punctures,  lacerations,  incisions,  and  contusions  may  be  the  result  of  accident 
or  design,  primary  or  secondary,  single  or  multiple,  involve  any  portion  of  one  or  both 
glands  to  the  degree  of  functional  disturbance  or  destruction. 

SYMPTOMS. 

Symptoms  associated  with  testicular  variations  are  simple  in  character,  therefore 
easy  to  determine  when  compared  to  the  deeper  structures  and  organs  of  the  perineum. 

Pain  is  not  always  confined  to  these  glands  because  of  their  inhibition  being  by 
branches  of  the  pudic  which  supplies  so  generally  the  perineum. 

The  milder  forms  of  testicular  conditions  usually  produce  local  symptoms,  while 
the  more  aggravated  forms  cause  both  local  and  general  symptoms,  severe  in  character 
because  all  of  the  reproductive  and  urinary  organs  are  likewise  disturbed,  especially  with 
the  acute  form  of  disease. 


Page   Ninety-Six 


CHAPTER  XVII. 


SPERMATIC  DUCTS. 

Epididymis.     Vas  Deferens.     Seminal  Vesicles.      Ejaculatory  Ducts. 

ANATOMY. 


0-tti  drtpry  of  rij>  Cefprerrs. 

LRllCAi  SECTION  Of  TCSTICLl  SHOWING 
THE  A)!fiANG[M[Nrt)r  THE  DUCT3 


"fSTtiE  AND  ihOj'Mii 


Fig.    52.       (Deaver.) 

PERMATIC  DUCTS  are  two  tortuous  canals,  one  on  either  side, 
that  connect  the  epididymi  \vith  the  urethra  and  thus  provide 
channels  for  the  escape  of  the  products  of  the  sexual  glands. 
Each  of  these  ducts  is  divided  into  the  vas  deferens  and  its  am- 
pulla and  the  ejaculatory  duct,  at  the  upper  end  of  the  latter  the 
spermatic  duct  is  connected  with  the  seminal  vesicles. 

The  spermatic  ducts  described  by  Deaver  are  pale  and  as- 
sociated with  pale  medullary  fibers  from  the  hypogastric  plexus 
of  the  sympathetic  nerve,  for  involuntary  muscle  fibres  accompany 
a  greater  part  of  the  duct  as  a  differential  plexus,  and  the  nerves 
of  the  testis  and  epididymis  are  sympathetic  fibers  for  the  walls 
of  the  blood  vessels  which  they  accompany  as  the  spermatic  and 
the  differential  plexuses  that  surround  the  corresponding  arteries. 
They  have  been  traced  into  the  muscular  tissue  and  the  mucosa. 
Within  the  muscles  they  form  the  dense  myospermatic  plexus. 


I'iige  Ninety-Seven 


Epididymis.  The  greatly  convoluted  beginning  of  the  seminal  ducts,  covers  the 
entire  posterior  border  and  outer  surface  of  the  testis. 

Blood  Supply.  Principally  the  deferential  vessels,  the  spermatic  emd  the  cremasteric 
arteries.  ^ 

Nerve  Supply.  Spermatic  and  deferential  plexuses  which  surround  the  correspond- 
ing arteries. 

Vas  Deferens.  This  tube  extends  from  the  epididymis  to  the  ejaculatory  duct  and 
includes  almost  the  entire  length  of  the  spermatic  duct. 

The  ejaculatory  duct  is  formed  by  the  union  of  the  ducts  of  the  corresponding  seminal 
vesicles  and  vas  deferens,  and  empties  into  the  urethra. 

Blood  supply  of  spermatic  ducts  is  chiefly  the  deferential  from  the  internal  iliac.  It 
also  receives  a  branch  from  the  middle  hemorrhoidal. 

Lymphatics  of  the  P'as  Deferens.  The  origin  of  the  collecting  trunks  of  the  deferens 
is  supposed  to  be  from  two  net  works,  viz. :  the  muscular  and  mucous.  Some  doubt,  how- 
ever, exists  since  the  latter  has  never  been  injected.  These  collecting  trunks  terminate  in 
external  retro-crural  gland  and  in  the  middle  chain  of  the  external  iliac  glands. 

Lymphatics  of  the  seminal  vesicles  arise  from  a  network,  which  is  formed  by  the 
anastomosis  of  two  networks.  One  originates  in  the  mucous  coat,  while  the  other  takes 
its  origin  in  the  muscular  coat. 

There  are  Two  Collecting  Channels.  They  anastomose  with  those  of  the  urinary 
bladder,  and  also  vary  much  from  those  from  the  prostate.  A  posterior  gland  of  the  ex- 
ternal iliac  group,  and  a  hypogastric  gland  are  the  terminals. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

Df    Benign. 
iseases    -I     ,,,  ,. 

t_    Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
partially  or  completely  absent,  long,  short,  large,  small,  sacculated,  patulous,  partially  or 
completely  closed,  for  a  short  or  long  period,  or  they  may  never  become  patulous. 


DISEASES. 

Benign.     Malignant. 

BENIGN. 

Inflammation  may  be  primary  or  secondary,  acute  or  chronic,  involve  a  part  or  all 
of  the  duct. 

Tuberculosis  may  be  acute  or  chronic,  primary  or  secondary,  single  or  multiple  in 
any  portion,  cease,  or  continue  to  develop,  disappear  spontaneouslj%  or  become  perma- 
nently destroyed. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
involve  any  portion,  continue  to  develop  or  disappear  spontaneously. 

Cysts  may  be  congenital  or  acquired,  acute  or  chronic,  primary  or  secondary,  single 
or  multiple,  gradually  or  suddenly  disappear  by  draining  into  the  urethra  or  rupturing 
into  the  surrounding  soft  structures  to  become  absorbed,  or  through  them,  externally  upon 
the  skin,  into  the  perineum,  scrotum,  rectum,  bladder  or  peritoneal  cavity. 

Page  Ninety  -Eight 


Fistula  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  through  the  external  soft  structures,  into  the  perineum,  rectum,  urethra,  or  peri- 
toneal cavity  and  several  channels  connect  two  or  more  organs  or  cavities. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple 
in  any  portion  of  the  lube,  vary  in  size,  shape  and  number. 

Lipomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
remain  stationary,  continue  to  grow  or  disappear  spontaneously. 

Concretions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, semisolid  or  hard,  vary  in  size,  shape  and  location,  remain  or  escape  into  or  through 
the  surrounding  soft  structures. 

Strictures  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
anywhere  in  the  ducts,  remain  temporary  or  permanent  (usually  permanent)  with  loss  of 
function. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary  (usually  primary)  single  or  multiple,  vary 
in  location,  involve  any  portion  of  one  or  both  at  the  same  time,  though  it  is  exceedingly 
rare  to  have  the  two  affected  simultaneously. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple  (rarely  multiple)  and 
affects  any  portion  of  the  duct. 

INJURIES. 

Injuries  may  be  contusions,  lacerations,  incisions,  or  punctures,  by  accident  or  de- 
sign, partially  or  completely  destroy  function  and  vary  in  degree  and  location. 

SYMPTOMS. 

Symptoms. 

Seminal   Vesicles. 

Local.     Inflammatory,  functional,  neurotic,  reflex. 

General.  Fuller  says :  Tenderness  is  referred  to  the  lateral  hypogastric  region  over 
the  sac,  to  the  lower  back  or  to  the  deep  perineum. 

Pain  intensified  by  acts  of  urination  and  defecation,  upright  positions  and  exercise, 
when  severe. 

Pain  along  cord,  into  testicle,  along  the  urethra,  down  the  thighs,  up  toward  the 
kidneys  or  into  the  rectum  at  onset,  sexual  function  is  excited,  strong  and  persisting  erec- 
tions, often  painful  chordee,  the  latter  suggesting  anterior  urethritis. 

Frequent  painful  emissions,  occasional  bloody  ejaculations. 

Frequent  micturition  and  tenesmus  suggesting  involvement  of  bladder.  All  of  these 
may  exist  without  cystitis. 

Rectal  tenesmus  and  straining  at  conclusion  of  the  act  of  defecation  or  urination. 

Bladder  disturbances  become  increased  with  partial  or  complete  retention  all  due 
to  distention  of  the  duct  because  symptoms  gradually  subside  with  drainage. 

Symptoms  of  spermatic  duct  involvement  are  not  altogether  determined  because  of 
their  concealment  within  the  deeper  structures  and  because  of  their  intimate  relation  with 
the  prostate,  urethra  and  bladder  above,  and  in  front,  rectum  behind  and  perineum  below. 

Neurotic  sensations  with  the  penis,  testicles  and  scrotum  may  exist  in  the  form  of 
pain   and   retraction. 

General  symptoms  are  neurotic  and  mental  to  the  degree  of  insomnia  increased  or  de- 
creased sexual  desire. 

Symptoms  of  conditions  involving  the  vas  deferens  like  other  external  genitalia  may 
not  be  easily  defined. 


Page   Ninety-Nine 


CHAPTER  XVIIl. 


SCROTUM. 
ANATOMY. 

"v  ^^       fe^  y\  ^^  SCROTUM,  sac-like  in  appearance,  is  composed  of  muscular 

W  Is.  fl  ^  fibers   known    as   the   dartos   muscle,    situated   in    the   superficial 

.^^^       h^>i^>,  fascia  and  skin,  containing  sweat  and  sebaceous  glands  with  their 

ducts  and  areolar  tissue,  in  all  of  which  there  is  an  absence  of 
fat.  The  tissue  within  the  median  line  known  as  the  raphe  is 
more  dense  and  capable  of  contraction. 

Blood  supply  is  from  the  superficial  perineal  branches  of 
the  internal   pudic   arteries   from  behind   and  the  external  putic 
branches  of  the  femoral  artery  above  and  in  front. 
Nerves. 

The  scrotum  in  the  male  and  labia  in  the  female  aie  sup- 
plied with  nerves  (Deaver)  from  the  lumbar  plexus,  which  go  to 
the  front  and  sides  of  the  scrotum  including  cutaneous  from  the 
genital  branch  of  the  genito-crural  nerve  usually  reinforced  by 
branches  from  the  ilio-inguinal  that  end  in  the  skin  in  the  vicinity 
of  the  root  of  the  scrotum,  emd  the  sacral  plexus  which  supplies  the  posterior  surface  of 
the  scrotum  and  are  from  the  perineal  or  inferior  pudendal  branches  of  the  small  sciatic 
nerves,  and  the  anterior  or  external  superficial  perineal  branches  of  the  pudic  nei'ves, 
sympathetic  fibers  accompanying  the  cutaneous  nerves  for  the  dartos  muscle.  Deaver  also 
states  that  scrotal  and  labial  pain  may  be  due  to  pressure  upon  the  trunk  of  the  inferior 
pudendal  nerve,  the  small  sciatic  or  that  portion  of  the  sacral  plexus  or  spinal  cord  from 
which  the  filaments  arise;  while  on  the  other  hamd,  pressure  upon  the  terminal  part  of  the 
inferior  pudendal  may  give  rise  to  pain  referred  to  the  back  of  the  thigh. 

External  L'^mphaiics  in  the  Male. 

Collecting  trunks  of  the  scrotum  are  divided  into  the  superior,  and  inferior.  There 
are  ten  or  fifteen  trunks  on  each  side  which  form  a  dense  network. 

Superior  collecting  trunks  originate  on  that  part  of  the  scrotum  which  is  a  continuation 
of  the  penile  raphe.  They  pass  upward  in  a  vertical  direction  to  the  root  of  the  penis, 
where  they  turn  obliquely  outwards,  running  parallel  with  the  collecting  trunks  of  the 
penis.  After  they  cross  the  spermatic  cord  they  tenninate  in  the  supero-internal  super- 
ficial inguinal  glands. 

Inferior  collecting  trunks  originate  below  and  posterior  to  the  superior  collecting  trunks. 
They  pass  to  the  lateral  parts  of  the  scrotum  in  an  upward  and  outward  direction  to  the 
lateral  part  of  the  scrotum,  from  whence  they  enter  and  follow^  the  cruro-scrotal  groove  for 
a  brief  distance,  and  then  pass  outwards,  terminating  in  the  inferior  internal  glands. 

Within  the  pre-symphysical  plexus  are  several  glandular  nodules.  This  plexus  is 
drained  by  a  number  of  collecting  trunks,  which  pass  into  the  inguinal  and  crural  canals. 

One  inguinal  collecting  trunk  passes  into  the  spermatic  cord,  and  terminates  in  the 
external  retro-crural  gland,  as  the  inguinal  collecting  trunk  enters  the  inguinal  canal,  it 
usually  gives  off  a  small  glandular  nodule. 


Page  One  Hundred 


The  crural  collecting  lrunl(s  are  three  or  lour  in  number.  They  pass  transversely 
outwards  under  the  femoral  aponeurosis  and  anterior  to  the  pectineus  muscle.  At  first 
they  are  in  a  single  bundle,  but  after  a  short  distance  they  diverge  in  a  vertical  direction, 
and  terminate  at  three  different  points.  The  lowest  terminates  in  the  deep  inguinal  gland, 
which  is  in  the  crural  canal  and  internal  to  the  femoral  vein.  A  second  terminates  in  the 
gland  of  Cloquet,  while  a  third  terminates  in  the  internal  retro-crural  gland,  which  is  on 
the  external  iliac  vein  within  the  pelvis, 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries  of  the  Scrotum. 
Anomalies. 

Diseases    {    ^5";.§"- 

l^    Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  of  the  scrotum  may  be  congenital  or  acquired,  primary  or  secondary,  large 
or  small,  short  or  long,  unilateral  or  partially  or  entirely  absent. 


DISEASES. 

Benign.      Malignant. 

BENIGN. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  vary  in  size  and  shape,  in  any  tissue  or  locality,  become  arrested,  con- 
tinue to  grow  or  disappear  spontaneously. 

Lipomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size  and  shape,  in  any  portion  of  the  scrotum. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
anywhere  in  the  scrotal  tissue,  vary  in  size  and  shape,  remain  stationary,  continue  to  grow 
or  disappear  spontaneously. 

Papillomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size  and  shape,  anywhere  upon  the  cutaneous  surface,  remain  stationary,  continue 
to  increase  in  size  and  number,  or  disappear  spontaneously. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  single  or  multiple,  con- 
tinue to  grow,  disappear  spontaneously,  and  appear  anywhere  in  the  scrotal  structures. 

S\)philis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
anywhere  in  the  scrotal  tissues,  in  the  form  of  chancre,  eruption  or  gumma. 

Foreign  bodies  enter  from  without,  vary  in  number,  character  and  extent  of  penetra- 
tion, encysted,  remain  indefinitely  without  causing  serious  trouble,  infected  and  expelled, 
complicated  with  injury  to  the  testicles  or  spermatic  ducts. 

C^sts  may  be  congenital  or  acquired,  single  or  multiple,  acute  or  chronic,  primary 
or  secondary,  contain  blood,  pus,  serum,  sebacious  matter,  dermoid  material  or  echinococci, 
vary  in  size,  rupture  externally  through  the  cutaneous  structures,  into  the  perineum,  rectum, 
bladder  or  into  the  soft  structures  of  the  upper  thigh,  perineum  or  groin. 

Fistula  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  penetrate  the  cutaneous  structures,  the  perineum,  urethra,  bladder,  sper- 
matic duct,  rectum  or  peritoneal  cavity. 

Pase   One   Hundred   One 


MALIGNANT. 

Carcinomaia  may  be  primary  or  secondary,  vary  in  size,  shape  and  location  and  be 
in  any  of  the  structures  usually  within  the  skin. 

Sarcomata  less  frequent,  primary  or  secondary,  vary  in  size,  shape  and  location  and 
originate  in  any  of  the  structures. 

INJURIES. 

Lacerations,  punctures,  incisions,  and  contusions  are  the  result  of  accident  or  design, 
primary  or  secondary,  vary  in  number,  degree  and  location,  sharp  or  ragged  in  any  tissue 
or  location. 

SYMPTOMS. 

Symptoms  scrotal  in  character  are  pain,  tenderness  and  induration,  mild  or  severe, 
local  or  general  or  both,  but  pain  and  tenderness  may  exist  in  scrotal  structures  free  from 
disease  or  injury,  because  of  their  richness  in  sensitive  nerve  fibers  and  intimate  relation 
with  other  structures  equally  well  supplied. 

Each  of  these  symptoms  may  be  primary  or  secondary  to  conditions  within  the  struc- 
tures contained  within  the  sac  or  tissues  far  distant  to  it,  especially  the  prostate,  urethra, 
bladder  or  rectum. 


Page   One   Hundred    Two 


CHAPTER  XIX. 


VAGINA. 


ANATOMY. 

^V    >-^  ""^^   /^  HE  VAGINA  originally  the  cloacal  chamber,  contains  the  clitoris, 
^1^  \l  ^  external  urinary  meatus  and  the  cervix  uteri  with  its  opening  sur- 

C>y>         5^S— ^^  rounded  by  mucous  membrane,  deeply  folded  to  form  the  major 

and  minor  labiae  which  form  its  outlet. 

The  hulho  cavernous  in  the  female  has  been  termed  the 
sphincter  vaginae,  the  two  muscles  of  opposite  sides  are  v/idely  sepa- 
rated from  each  other  by  the  vagina  which  they  surround.  They 
arise  from  the  central  tendon  of  the  perineum,  pass  forward  invest- 
ing the  bulbi  vestibule  and  are  lost  in  the  fascia  covering  the  cor- 
pora cavernosa  and  the  dorsal  surface  of  the  clitoris. 

Vaginal  mucous  membrane  has  a  stratified  scaly  epithelium 
and  is  corrugated  by  a  number  of  transverse  ridges  called  rugae 
vaginales.  There  is  also  a  transverse  rugae  on  the  anterior  and 
posterior  wall  of  the  vagina  especially  seen  in  young  subjects  in 
the  lower  part  of  the  vagina.  Within  the  mucous  coat,  nodules 
of  lymphoid  tissue  are  found,  and  the  vaginal  wall  is  surrounded  by  loose  vascular  con- 
nective tissue,  containing  many  large  communicating  veins. 

The  blood  supply  is  mostly  from  the  branches  of  the  vesico-vaginal  artery,  vaginal 
branch  of  the  uterine  artery,  vaginal  branches  of  the  middle  hemorrhoidal  and  internal 
pudic  arteries. 

The  veins  surrounding  the  vaginal  wall  drain  their  contents  into  the  internal  iliac  vein. 
Nerves  supplying  the  vagina,  according  to  Piersol,  are  from  the  hypogastric  sympa- 
thetic plexus  through  the  pelvis  and  from  the  second,  third  and  fourth  sacral  nerves.  The 
immediate  source  of  the  sympathetic  fibers  is  from  the  cervical  ganglia  at  the  side  of  the 
neck  of  the  uterus  from  which  in  association  with  the  sacral  branches,  twigs  pass  to  and 
from  each  side  of  the  vaginal  plexus  that  embraces  the  vagina  and  filaments  chiefly  for 
the  involuntary  muscle  of  its  walls  and  blood  vessels.  Sensory  fibers  are  few  in  the 
vaginal  mucous  membrane  so  that  the  upper  vagina  has  but  slight  sensibility  though  it  is 
greatly  increased  as  the  vaginal  orifice  is  approached  by  the  pudic  fibers  which  supply  the 
mucous  membrane  and  which  send  motor  fibers  to  the  striated  muscle  surrounding  the 
entrance. 

Lymphatics  of  the  Female.  The  female  sexual  organs  are  external  and  internal, 
and  have  their  corresponding  lymphatics.  Therefore,  the  lymphatics  of  the  external  and 
internal  genitalia  are  considered  separately.  The  lymphatics  of  the  vulva  arise  from  a  net- 
work which  is  arranged  in  several  planes  and  which  covers  the  forchette,  meatus  urinarius 
vestibule,  labia  minora,  labia  majora  and  clitoris.  Drainage  of  this  meshwork  is  accom- 
panied by  collecting  trunks  which  take  an  upward  and  forward  direction  to  the  mons 
veneris  where  they  change  abruptly  into  a  transverse  direction  towards  the  superficial 
inguinal  glands.  The  collecting  trunks  arising  from  the  posterior  two-thirds,  take  an  up- 
ward and  outward  direction  before  reaching  their  tenninal  glands.  The  termination  of 
the  vulva  glands  is  the  superior-internal  group,  inferior-internal  group  or  one  of  the  ex- 
ternal groups.  They  usually,  however,  terminate  in  the  former  group,  rarely  in  the  latter 
group. 

Page  One  Hundred  Three 


Lymphatics  of  the  Vagina.  Two  kinds  of  tissue  are  drained  by  the  vaginal  lym- 
phatics: mucous  membrane  cind  muscular  respectively. 

Those  which  drain  the  mucous  membrane  are  beneath  the  epithelium,  and  are  com- 
posed of  a  very  fine  and  dense  network.  The  muscular  lymphatics  are  the  coarser  ftf  the 
two. 

The  collecting  trunks  of  the  vaginal  lymphatics  are  divided  into  three  groups,  viz. : 
the  superior,  middle  and  inferior  group. 

The  superior  group  drains  the  upper  third  of  the  vagina.  Two  collecting  trunks  arise 
from  this  group.  One  arises  anterior  to  the  cervix,  while  the  other  arises  posterior  to  the 
cervix. 

The  anterior  collecting  trunk,  after  passing  upward,  outward  and  anterior  to  the 
ureter,  receives  several  cervical  trunks  and  terminates  in  the  middle  gland  of  the  middle 
chain  of  the  external  iliac  group.  ■ 

The  posterior  collecting  trunk  takes  an  upward  and  outward  direction  and  ter- 
minates either  in  the  middle  gland  of  the  middle  chain  of  the  external  iliac  group,  or  in 
the  posterior  gland  of  this  group. 

The  middle  group  drains  the  middle  third  of  the  vagina.  Its  direction  is  upward, 
backward  and  outward,  and  corresponds  to  the  direction  taken  by  the  vaginal  artery.  The 
termination  is  a  gland  of  the  hypogastric  group,  which  is  located  in  the  hypogastric  space 
at  the  origin  of  the  vaginal  artery. 

The  inferior  group  collecting  trunks  arise  in  the  third  of  the  recto-vaginal  septum. 

first — These  collecting  trunks  descend,  then  pass  outward  and  backward,  after 
which  they  pass  upward  into  the  cavity  of  the  sacrum,  internal  to  the  sacral  foramen  and 
terminate  usually  in  the  glands  of  the  promontory  group.  Occasionally  they  terminate  in 
the  lateral  sacral  glands. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

T-N-  r    Benign. 

Diseases    |    ^^^^^^,^ 

Injuries. 

Anomalies.  A  part  or  all  of  the  vaginal  tissues  may  be  absent.  The  cavity  large  or 
small,  irregular  in  shape,  entirely  absent,  septinated,  deep,  shallow  or  narrow  and  have 
one  or  more  external  or  internal  openings-  those  internal  entering  the  rectum,  bladder  or 
peritoneal  cavity. 


DISEASES. 

Benign.     Malignant. 

BENIGN. 

Vaginitis  may  be  primary  or  secondary,  acute  or  chronic,  mild  or  severe  and  involve 
a  part  or  all  of  the  vaginal  mucosa. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  vary  in  size,  shape  and  depth,  in  any  tissue  or  portion  of  the  vaginal  wall, 
cease,  continue  to  grow,  or  disappear  spontaneously. 

Papillomata  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
in  any  portion  of  the  mucous  membrane,  especially  upon  the  muco-cutaneous  border,  vary 
in  size  and  shape,  usually  pedunculated,  cease,  continue  to  grow  or  disappear  spon- 
taneously. 

Page  One  Hundred  Four 


Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape  and  location,  have  a  broad  ba^e  or  pedicle,  cease,  continue  to  grow  or 
disappear  spontaneously,  though  such  a  resolution  seldom  occurs. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  usually  primary, 
single  or  multiple,  vary  in  size  and  shape,  in  any  portion  of  the  vaginal  tissue,  especially 
the  muscularis. 

Lipomata  may  be  congenital  or  acquired,  usually  primary,  single  or  multiple,  vary  in 
size,  shape,  anywhere  in  the  vaginal  tissues. 

Cysts  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary,  acute 
or  chronic,  in  any  tissue  or  portion  of  the  vaginal  wall,  rupture  into  the  vagina,  rectum, 
perineum,  urethra,  bladder,  uterus  or  peritoneal  cavity,  remain  undisturbed,  contain  blood, 
pus  or  serum,  urine,  echinococci  or  dermoid  material. 

Fistula  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
acute  or  chronic,  enter  the  vagina,  rectum,  urethra,  bladder,  uterus,  peritoneal  cavity,  pass 
into  or  through  the  perineal  body  or  soft  structures  of  the  upper  thigh. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  single  or  multiple,  usually  primary  ajid 
single,  originate  in  any  tissue  or  portion  of  the  vaginal  wall. 

Sarcomata  may  be  single  or  multiple,  primary  or  secondary,  vary  in  size  and 
originate  in  any  tissue  or  portion  of  the  vaginal  wall. 

INJURIES. 

Lacerations,  incisions,  punctures,  may  be  by  accident  or  design,  single  or  multiple, 
primary  or  secondary,  longitudinal  or  circular,  partial  or  complete,  in  any  portion  of  the 
vaginal  wall. 

Foreign  bodies  may  be  by  accident  or  design,  single  or  multiple,  enter  through  the 
vaginal  outlet,  rectum,  perineum,  bladder  or  peritoneal  cavity  and  escape  through  their 
outlets. 

SYMPTOMS. 

The  many  conditions  that  may  exist  within  the  vagina  render  it  productive  of  a  great 
many  local  and  general  physiologic  symptoms,  very  similar  in  character. 

Local  pain,  tenderness  and  induration  and  general  nervous  disturbances  are  of  the 
greatest  consideration  and  probably  more  definite  in  this  than  the  other  reproductive  organs 
of  the  female. 

It  is  only  the  milder  forms  of  vaginal  conditions  that  produce  local  symptoms  alone, 
but  they  often  produce  rectal  or  urinary  disturbances  of  an  aggravated  form,  but  these 
two  tracts  seldom  escape  the  influences  of  the  more  severe  conditions,  especially  when  they 
are  in  close  proximity. 


Page  One   Hundred   Five 


CHAPTER  XX. 


BARTHOLIN  GLANDS. 
ANATOMY. 


J^tl^7tc^.£J^  ^cuu^<^. 


Fig.  53. 

ARTHOLIN  GLANDS  in  the  female  are  the  homologues  of 
Cowper's  glands  in  the  male.  They  are  a  small  pair  of  organs 
situated  one  on  either  side  of  the  vaginal  orifice,  behind  the 
bulbus  vestibuli  and  about  the  middle  of  the  base  of  labium  major. 
The  duct  merges  from  the  anteromedial  border  of  the  gland.  It 
is  a  small  tube  about  2  mm.  in  diameter  and  about  Yl  cm.  long, 
and  opens  into  the  vaginal  orifice  between  the  nymphae  cind  the 
hymen. 

Its  structure  corresponds  to  the  mucous  tubo-alveolar  type, 
the  small  component  lobules  however,  being  separated  by  fibro- 
muscular  tissue,  the  terminal  compartments  are  lined  by  columnar 
epithelium  and  contain  numerous  goblet  cells. 

The  main  duct  sometimes  has  ampulary  enlargements.  The 
secretion  of  the  gland  is  whitish  in  color  and  viscid. 

Blood  Suppl]).  The  arteries  supplying  this  gland  are  twigs 
given  off  from  the  bulbar  branch  of  the  internal  pudic.  The  veins  are  tributaries  chiefly 
to  the  internal  pudic  but  also  communicate  to  the  trunks  of  the  vestibular  bulb  and  the 
vagina. 


Page    One    Hundred    Six 


Nerves  are  very  numerous  and  include  sympathetic  fibers  and  twigs  from  the  pudic. 
Lymphatics.     The  lymphatics  join  those  of  the  vagina  and  rectum  that  are  afferents 
of  the  internal  iliac  nodes. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 
Anomalies. 

Diseases    !     P5";.g"- 

(     Malignant. 

Injuries. 

ANOMALIES. 

Anomalies.  The  glands  of  the  two  sides  often  vary  in  size  and  may  be  asym- 
metrically placed.  The  ducts  may  be  double  and  the  lobules  so  separated  that  the  usual 
gland  mass  is  replaced  by  isolated  divisions  or  sometimes  seemingly  wanting  on  one  or 
both  sides. 


DISEASES. 

Benign.     Malignant. 
BENIGN. 

Inflammation  may  be  primary  or  secondary,  acute  or  chronic,  unilateral  or  bilateral 
and  vary  in  degree. 

Papillomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size, 
number,  shape  and  location. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  and  location. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  contain 
blood,  pus,  or  serum,  vary  m  size,  shape,  number  and  location,  rupture  through  the  cu- 
taneous structures,  their  natural  course,  into  the  vagina  or  rectum. 

Fistula  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  vary  in  size,  shape,  length,  open  through  the  skin  into  the  vagina  or  rectum. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  vary  in  size,  character,  shape,  location 
and  rate  of  growth. 

Sarcomata  may  be  primary  or  secondary,  vary  in  size,  shape,  character,  location  and 
rate  of  growth. 

INJURIES. 

Incisions,  punctures,  contusions  may  be  accidental  or  induced,  primary  or  secondary, 
vary  in  degree  and  severity. 

SYMPTOMS. 

Symptoms  such  as  pain,  tenderness,  redness  and  induration  are  most  prominent.  They 
may  vary  in  degree  and  severity,  local  or  general  in  their  manifestations,  and  when  gen- 
eral, are  difficult  to  recognize. 


Page  One  Hundred  Seven 


CHAPTER  XXI. 


CLITORIS. 
ANATOMY. 


^JLijbsyi^ 


Fig.    54. 

VS.  (^       rJ)  j\  ^^  ERECTILE  BODY  (clitoris  in  the  female) ,  is  the  analogue 
jpj  I  J.         Ji  W  of  the  penis  in  the  male  and  is  therefore  to  be  considered  much 

S-vfH       K^\^^  in  the  same  manner   symptomatically.      It  is   buried  in  such   a 

manner  beneath  the  labia  that  only  its  small  conical  anterior  end 
and  the  lower  vertical  ridge  of  integument  over  the  body  appear 
when  the  labiae  are  separated. 

Blood  Supply.  The  vessels  supplying  blood  to  the  clitoris 
correspond  with  those  of  the  penis  but  are  smaller  and  the  same 
arrangement  is  found  with  the  veins. 

Nerve  supply  in  its  derivation  and  distribution  is  the  same 
as  found  in  the  penis,  being  from  the  sympathetic  system  for  the 
walls  of  the  blood  spaces  and  from  the  pudic  nerves.  The  dor- 
sal nerve  is  relatively  larger  and  supplies  the  integument  of  the 
glans  and  prepuce  with  fibers  connected  with  special  sensory  end 
organs   (Piersol). 

Clitoris.  The  lymphatic  glands  of  the  prepuce  terminate  in  the  superficial  inguinal 
glands.  Those  of  the  glands  clitoris  resemble  the  lymphatics  in  the  male.  Their  origin  is 
composed  of  a  network  which  empties  into  several  collecting  trunks.  They  pass  along  the 
dorsum  of  the  clitoris  to  a  point  anterior  to  the  symphysis,  where  in  their  union  the  pre- 


pare One  Hundred  Eight 


symphysical  plexus  is  formed.  Two  collecting  find  their  origin  in  this  plexus.  One  made 
up  of  a  small  chain  of  glandular  trunks  passes  along  the  canal  of  the  neck,  beneath  the 
round  ligament  to  the  retro-crural  glands.  The  other  trunk  runs  towards  the  canal  of 
the  neck  and  terminates  in  the  gland  of  Cloque,  the  retro-crural  and  deep  inguinal  glands. 
The  clitoris  has  five  times  as  many  nerves  as  the  penis  and  is  supplied  with  sympathetic 
nerves  which  are  freely  anastomosed  with  the  cerobrospinal  nerves. 

S\)mf}toms  such  as  pain,  tenderness  and  general  sexual  irritability  are  most  common 
and  important.  The  existence  of  pathology  of  any  kind  within  or  about  the  clitoris  will 
cause  irritation  of  the  sensory  nerve  fibers  which  it  contains  and  consequently  many  ag- 
gravated general  disturbances,  such  as  headache,  nausea,  vomiting  and  sexual  desire 
(See  Chapter  Male  Erectile  Body.) 


Page   One   Huiulreil    Nine 


CHAPTER  XXII. 


UTERUS. 


ANATOMY. 

f^  ^rnm^       ^^    j^  HE  UTERUS  constitutes  in  weight  a  larger  amount  than  all  of 
^^  1^  f /  (^  ^^^  other  reproductive  organs  in  the  female,  and  because  of  this 

\^j^         5x0^,  ^^  ^^  probably  more  frequently  the  seat  of  pathology,  especially 

with  the  addition  of  pregnaint  conditions.     It  must,  therefore,  play 
a  prominent  role  in  symptomatology. 

Blood  supply  is  from  the  two  uterine,  each  a  branch  of  the 
internal  iliac  that  accompanies  the  ureter  along  the  pelvic  wall, 
behind  and  below  the  ovarian  fossa,  to  the  attached  border  of 
the  broad  ligament  beneath  which  it  passes  in  its  course  to  the 
ureters. 

As  it  is  not  necessary  to  describe  in  further  detail  the  blood 
supply  of  this  organ  the  subject  will  be  concluded  by  reference 
to  its  intimate  blood  relation  to  the  entire  uro-genital  and  rectal 
tracts.      (See  Piersol,  pp.  2009-2010.) 

Uterine  nerves  are  large  and  for  involuntary  muscles  and 
derived  from  the  sympathetic  system,  the  (utero-vaginal  subdivisional)  of  the  pelvic  plexus, 
but  directly  from  the  second,  third  and  fourth  sacral  spinal  nerves. 

The  utero-vaginal  plexus  divide  into  two  parts,  the  smaller  for  the  posterior,  and  the 
lateral  parts  of  the  uterus.  The  larger  consists  of  a  chain  of  small  ganglia  along  the 
cervix  and  vaginal  vault. 

Sympathetic  nerves  supply  involuntary  muscular  walls  of  the  uterus  and  tubes  so 
that  irritation  from  the  generative  organs  travels  to  the  abdominal  brain  by  way  of  the 
ovarian  and  hypogastric  plexuses.  Uterine  and  tubal  neuralgia  is  thus  explained.  Lacera- 
tion of  the  cervix  pathologic  in  character  for  five  years  has  been  described  by  Sutton  as 
being  the  cause  of  confirmed  neurasthenia. 

Lymphatics  of  the  Uterus.  The  uterine  lymphatics  originate  in  the  mucous  mus- 
cular and  peritoneal  coasts  respectively.  A  network  is  formed  by  their  anastomosis  in  the 
sub-peritoneal  cellular  tissue.  The  collecting  trunks  number  four  or  five.  The  networks 
which  originate  at  the  cervix  or  corpus  uteri  are  continuous,  yet  the  cervical  or  corporal 
collecting  trunks  are  considered  separately. 

Cervical  collecting  trunks  number  from  four  to  eight.  They  form  the  large  lymphatic 
knot  after  leaving  the  cervix.  This  knot  is  called  the  juxta-cervical  knot,  it  is  often  absent 
in  the  new-born,  but  alv/ays  present  when  pregnancy  exists.  The  cervical  collecting  trunks 
are  subdivided  into  three  groups,  viz. :    primary,  secondary  and  lateral  sacral  groups. 

Primary  Croups.  There  are  two  or  three  collecting  trunks  in  the  primary  group,  they 
converge  towards  the  lateral  portions  of  the  corpus-uteri.  They  usually  pass  upward  and 
anterior  to  and  above  the  ureter.  Occasionally  their  course  is  posterior  and  sub-ureteral. 
After  accompanying  the  uterine  artery  for  a  short  distance,  the  lymphatics  leave  the 
uterine  artery  and  pass  up  the  lateral  wall  of  the  pelvic  cavity  internal  to  the  hypogastric 
artery  in  the  adult,  cross  it  in  the  foetus.  They  terminate  in  the  middle  and  superior  gland 
of  the  middle  chain  of  the  external  iliac  group. 

The  juxta-cervical  gland  was  first  discovered  by  M.  Lucas  Championniere.  It  is 
occasionally  found  as  an  interrupting  glandular  nodule  by  the  side  of  the  cervix.     Revnier 


Page    One    Hundred    Ten 


"is  of  the  opinion  that  the  juxta-cervical  gland  is  an  hypertrophied  gland  due  to  a  patho- 
logical process." 

Secondary)  or  hypogaslr'ic  group  originates  on  the  same  level  as  the  primary  group. 
It  passes  posteriorly  to  and  below  the  ureter  after  which  it  passes  upward,  backward  and 
outward  terminating  in  a  gland  of  the  hypogcistric  group  on  the  anterior  surface  of  the 
hypogastric  artery  on  a  level  with  the  uterine  and  vaginal  arteries. 

The  lateral  sacral  group  is  composed  of  two  or  three  collecting  trunks  which  originate 
on  the  posterior  cervical  surface,  after  which  they  pass  backward  and  continue  across  the 
lateral  part  of  the  rectum  through  the  utero-sacral  ligaments,  from  which  they  pass  upward 
into  the  cavity  of  the  sacrum.  1  wo  terminals,  the  lateral  sacral  and  the  promontory  glands. 
The  former  receives  the  external  or  shorter  collecting  trunks,  while  the  latter  receives  the 
internal  or  longer  collecting  trunks. 

Collecting  trunks  of  the  corpus  uteri  are  three  in  number,  one  primary  and  two  ac- 
cessory collecting  trunks.  The  primary  collecting  trunk  subdivides  into  four  or  five  small 
collecting  trunks  which  originate  below  the  uterine  cornu.  From  their  origin  their  course 
corresponds  to  the  termmal  segment  of  the  uterme  artery,  after  which  they  pass  beneath 
the  ovary  to  be  joined  by  the  ovarian  ligament.  As  they  continue  in  an  upward  direction 
towards  the  lumbar  region,  they  pass  around  the  blood  vessels  and  with  them  cross  the 
hilum  of  the  kidney,  then  turn  acutely  and  descend  to  the  juxta-aortic  glands.  Some  how- 
ever, may  terminate  in  the  pre-aortic  group. 

Accessory  trunks  are  two  in  number,  viz. :  primary  and  secondary.  The  primary 
trunk  may  be  composed  of  one  trunk  or  be  subdivided  into  two  trunks.  Just  below  the 
uterine  cornu  is  their  point  of  origin.  They  pass  outward  and  terminate  in  the  middle  chain 
of  the  external  iliac  group.     This  chain  therefore  receives  cervical  and  corporeal  lymphatics. 

Secondary  collecting  trunlf  is  difficult  to  trace  to  its  termination,  which  is  the  super- 
ficial gland  of  the  supero-internal  group. 

Infections  are  carried  upward  by  the  retro-peritoneal  glands  to  the  thoracic  duct  frorn 
the  uterus. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 
Anomalies. 

Diseases     f    P/^/.S"" 

■\     Malignant. 

Injuries. 

ANOMALIES. 
Anomalies  may  be  congenital  or  acquired,  single  or  multiple,  primary  or  secondary, 
vary  in  form,  number  and  position,  number  of  cavities  or  the  entire  absence  of  a  cavity. 
The  cervix  may  be  long  or  short,  small,  irregular  in  shape,  diameter,  position,  septinated, 
contain  more  than  one  canal,  entirely  absent  (uterusacoulis) ,  open  into  the  bladder,  urethra, 
rectum  or  peritoneal  cavity.  [(See  Anomalies  of  the  Uterus)  (Ricketts)  Cin.  Lancet 
Clinic    (xlvii.,  page  554.)] 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Endometritis  may  be  primary  or  secondary,  acute  or  chronic,  local  or  general,  mild  or 
severe. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  vary  in  degree,  in  any  tissue  or  portion  of  the  uterus,  cease  or  continue  to  grow 
or  disappear  spontaneously. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple. 

Page  One  Hundred  Eleven 


pedunculated,  hard  or  soft,  vary  in  shape  or  size,  in  any  portion  of  the  uterine  wall,  at- 
tached to  any  of  the  abdominal  viscera  or  abdominal  w^all,  become  cystic,  rupture  into  the 
uterine  or  peritoneal  cavity,  rectum,  vagina  or  bladder. 

Papillomata  may  be  congenital  or  acquired,  primary  or  secondary,  single^or  mul- 
tiple, vary  in  size  or  shape,  with  or  without  pedicle,  anywhere  upon  the  external  or  in- 
ternal surfaces. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size  and  shape,  with  or  without  pedicle  (usually  without),  anywhere  upon  the 
external  or  internal  surface. 

Pregnancies  may  be  normal  or  abnormal,  single  or  multiple,  become  attached  any- 
where upon  the  mucous  surfaces  or  upper  cervical  canal,  escape  through  the  cervical  canal, 
uterine  wall  into  the  rectum,  intestinal  canal,  bladder,  peritoneal  cavity,  Hfe  of  the  foetus 
become  extinct  during  any  period  of  development,  and  the  body  remain  indefinitely  within 
the  uterine  cavity. 

Procidentia  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  degree 
from  slight  to  complete,  return  spontaneously  to  the  normal  position  where  it  may  remain 
indefinitely,  or  descend  to  ciny  degree  at  any  age  and  remain  without  ever  having  been 
impregnated, 

C^sts  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  contain  blood,  pus,  serum,  urine,  feces,  echinococci,  dermoid  or  colloid  material, 
rupture  into  the  uterus,  bladder,  rectum,  peritoneal  cavity,  intestmal  canal  or  externally 
through  the  skin  or  perineum. 

Fistula  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  enter  the  bladder,  uterus,  rectum,  peritoneal  cavity,  intestinal  canal,  perineum  or 
pass  through  the  external  cutaneous  structures. 

MALIGNANT. 
Carcinomata  may  be  primary  or  secondary,  single  or  multiple,  in  any  tissues  of  the 
uterine  body,  especially  the  cervix. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple,  hard  or  soft,  in  any  of 
the  tissues  of  the  uterine  body. 

INJURIES. 

Lacerations,  punctures,  and  ruptures  may  be  complete  or  incomplete,  the  result  of  acci- 
dent or  design,  from  within  or  without,  single  or  multiple,  longitudional  or  circular,  pene- 
trate into  the  peritoneal  cavity,  bladder,  vagina,  rectum,  the  overlying  soft  structures,  or 
indirectly  into  the  intestinal  canal,  blood  vessels,  ureters  or  Fallopian  tubes. 

Foreign  bodies  may  be  by  accident  or  design,  single  or  multiple,  vary  in  character, 
enter  through  the  vaginal  and  cervical  canals,  bladder,  rectum,  or  peritoneal  cavity,  the 
overlying  soft  structures  or  make  their  exit  through  these  structures. 

SYMPTOMS. 

Symptoms  ascribed  to  the  uterus  highly  dominate  the  adjacent  organs  and  soft  struc- 
tures because  of  richness  in  sensory  nerve  fibers  from  the  pudic  and  their  coalescence  with 
sensory  fibers  from  the  same  source. 

The  same  group  of  symptoms  are  manifested  with  all  and  probably  to  the  same  de- 
gree throughout  their  existence  whether  they  be  mild  or  severe. 

This  organ  normally  being  the  largest  of  the  perineal  and  pelvic  structures,  and 
varying  so  greatly  in  size  during  pregnancy  and  disease,  and  possessing  such  a  great  blood, 
lymphatic  and  nerve  supply,  places  it  first  in  variety  of  pathology  and  symptomatology.  It 
must  also  be  the  greatest  factor  in  their  complications. 

Local  manifestations  such  as  pain  and  tenderness  are  most  prominent  and  may  be 
more  readily  defined  than  other  pelvic  organs  when  involved  without  the  manifestations  of 
chill,  headache,  shock,  perspiration,  nausea  and  vomiting. 

The  various  forms  of  uterine  pregnancies  are  without  doubt  the  more  common  ex- 
citing causes  of  these  manifestations.  Next  in  frequency  are  accidents  incident  to  preg- 
nancy, but  uterine  pathology  of  any  kind  may  cause  similar  manifestations. 

Page    One    Hundred    Twelve 


CHAPTER  XXIII. 


OVARIES. 
ANATOMY. 


'>^ 


vr''^ 


Fig.    55. — Ovary    and    Blood    Vessels    (Kelley). 

^(il       (T)  A\^^  normal  ovary  is   about  the  size  of   a  large  almond 
^)1.         4v  7  ^^-^^''  ^^  connected  with  the  broad  ligament  by  peritoneal  folds 

-     />H       K\N-/,  though  not  firmly  fixed  in  any  definite  place.     The  upper  end  of 

the  ovary  is  termed  the  tubal  pole  as  it  is  more  intimately  con- 
nected with  the  Fallopian  tube.  The  lower  end  is  termed  the 
uterine  pole  because  it  is  connected  with  the  uterus  by  a  fibrous 
cord  known  as  the  ovarian  ligament.  The  anterior  border  is 
termed  the  hilum  of  the  ovary. 

Ovarian  is  the  only  tissue  capable  of  regenerating  itself  or 
any  other  tissue  of  the  body.  It  has  been  known  to  reproduce 
functional  ovarian  tissue,  muscle,  fat,  tendon,  cartilage,  bone, 
teeth  and  hair  and  parts  of  various  organs. 

It  is,  therefore,  important  that  all  ovarian  tissue  should  be 

removed  when  menstruation  is  to  be  prevented,   or  regeneration 

of  such  tissue  is  to  be  avoided.     The  benefits  to  be  derived  from 

the  knowledge  of  the  absence  of  any  ovarian  tissue  whatever  are  great  from  a  symptomatic 

point  of  view,  because  their  symptoms  cannot  then  exist. 

Blood  vessels  correspond  to  the  spermatic  arteries  of  the  male,  springing  from  the 
anterior  aspect  of  the  aorta  below  the  level  of  origin  of  the  renal  vessels,  each  gaining 
the  pelvis  in  the  fold  of  the  peritoneum  forming  the  suspensory  ligament  of  the  ovary,  and 
enters  the  ovary  at  its  anterior  border.  These  arteries  anastomose  freely  near  the  hilum 
with  vessels  derived  from  the  uterine  arteries. 


Page   One   Hundred   Thirteen 


The  blood  is  returned  by  communicating  veins  similar  to  the  pampiniform  plexus  in 
the  male. 

Nerves  are  from  a  plexus  which  accompanies  the  ovarian  artery  and  which  is  con- 
tinuous above  with  the  renal  plexus.  Other  fibers  are  derived  from  the  lower  part 
of  the  aortic  plexus  and  join  the  plexus  on  the  ovarian  artery.  The  afferent  impulsfe  from 
the  ovary  reach  the  central  nervous  system  through  the  posterior  root  fibers  of  the  tenth 
thoracic  nerve. 

Ovarian  lymphatics  form  a  dense  plexus,  which  when  infected  overshadows  the  sub- 
jacent venous  plexus.  After  the  plexus  becomes  smaller,  four  to  six  collecting  trunks  are 
formed.  They  take  an  upward  course  with  the  ovarian  vessels,  pass  anteriorly  to  the 
common  iliac  vessels  and  ureter  accompanying  and  then  anastomose  with  lymphatics  from 
the  Fallopian  tube  and  uterine  fundus  at  the  fifth  lumbar  vertebra,  after  which  they 
terminate  in  the  lateral  aortic  glands.  One  vessel  passes  downward  and  slightly  outward 
into  the  superior  part  of  the  ligament  and  terminates  in  one  gland  of  the  middle  chain  of 
the  internal  iliac  group.  Marcille,  Zeissl  and  Horowitz  have  one  of  the  testicular  lym- 
phatics end  in  the  same  gland  of  the  abdomino-aortic  group. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies, 

Diseases   |    ^f^"-    ^ 
[    Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
in  form,  size,  shape  and  position.     When  single  they  are  invariably  of  horse-shoe  shape. 


DISEASES. 

Benign.     Malignant. 
BENIGN. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape  and  location. 

Papillomala  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, vary  in  size,  shape  and  location,  with  or  without  pedicles  and  disappear  spontaneously, 
though  this  is  a  rare  occurrence. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  vary  in  size,  shape, 
number  cind  location,  with  or  without  pedicles,  usually  without,  and  seldom  disappear 
spontaneously. 

Pregnancies  of  the  ovaries  are  of  rare  occurrence,  with  considerable  doubt  as  to  the 
possibility  of  multiple  ovarian  pregnancies.  They  may  mature  without  rupture,  become 
encysted  and  remain  indefinitely,  or  rupture  at  any  period  during  development  into  the 
peritoneal  or  intestinal  cavity,  bladder,  uterus,  rectum  or  vagina. 

Adhesions  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
with  or  without  disease,  to  the  uterus,  Fallopian  tubes,  bladder,  intestines,  appendix,  rectal 
or  vaginal  wall. 

C'^sts  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  contain  blood,  pus,  serum,  echinococci,  fecal,  colloid  or  dermoid  material. 

Page  One  Hundred   Fourteen 


rupture  into  the  peritoneal  cavity,  Fallopian  tube,  uterus,  bladder,  intestinal  tract,  rectum 
or  vagina. 

Hernia  of  the  ovaries  may  be  congenital  or  acquired,  primary  or  secondary,  uni- 
lateral or  bilateral,  through  the  femoral  or  inguinal  ring,  into  the  labia,  bladder,  rectum  or 
vagina. 

Fisiulce  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  open  into  the  peritoneal  cavity.  Fallopian  tube,  uterus,  bladder,  intestinal 
canal,  rectum,  vagina  or  perineum. 

MALIGNANT. 

Carc'inomata  may  be  primary  or  secondary,  usually  primary,  involving  one  or  both 
ovaries,  rarely  both,  in  any  portion  of  the  gland  and  extend  into  the  surrounding  structures. 

Sarcomala  may  be  primary  or  secondary,  usually  primary,  involve  one  or  both 
ovaries  and  extend  into  the  ovarian  ligament  first,  broad  ligament  tube,  uterus  and  sur- 
rounding soft  structures  like  carcinoma. 

INJORIES. 

Ruptures,  incisions,  punctures  and  lacerations  may  be  by  accident  or  design,  primary 
or  secondary,  single  or  multiple,  penetrating  or  non-penetrating,  in  any  portion  of  the  ovary, 
extend  into  the  peritoneal  cavity.  Fallopian  tube,  uterus,  bladder,  vagina,  rectum,  peri- 
neum, appendix,  intestinal  canal  or  externally  into  the  soft  structures  or  through  the  skin, 
anywhere  about  the  pelvis. 

SYMPTOMS. 

Symptoms  such  as  obtain  with  ovaries  even  when  aggravated  by  profound  pathology 
are  very  indefinite.  This  is  especially  so  with  the  earlier  manifestations,  which  are  so  often 
slight  in  character,  and  because  the  nerve  fibers  are  from  the  same  source  and  intimately 
associated. 

Pain  having  its  origin  in  one  would  be  reflected  to  the  other  and  thus  involve  the 
uterus  and  surrounding  structures  which  are  also  dominated  by  branches  of  the  pudic. 

This  being  so,  primary  pain  of  one  structure  would  become  secondary  with  others, 
especially  the  Fallopian  tubes  and  uterus. 

Local  disturbances  in  the  ovaries  are  in  the  form  of  pain  and  tenderness,  sometimes 
induced  by  the  sense  of  touch.  Like  their  analogue  the  testicles,  they  are  more  sensitive 
than  any  other  tissue  in  the  uro-genital  tract,  and  their  sensitiveness  increases  with  pathology. 
Their  irregularities,  therefore,  are  more  readily  reckoned  with  and  defined,  especially  when 
general  disturbances  are  manifested.  Pressure  upon  a  normal  ovary  will  Induce  tenderness, 
pain,  chill,  headache,  shock,  nausea  and  vomiting.  It  is  therefore  apparent  why  they 
are  so  greatly  influenced  by  pathology  within  them  or  their  adjacent  structures  or  those 
far  distant  within  the  pelvis  or  perineum,  that  possess  the  same  nerve  supply.  The  very 
great  variety  of  conditions  to  which  the  ovaries  are  subjected,  produce  symptoms  Identical 
in  character  thus  rendering  It  impossible  to  identify  any  one  of  them. 


Page    One    Hundred    Fifteen 


CHAPTER  XXIV. 


FALLOPIAN  TUBES. 
ANATOMY. 


fig,.    56. — Fallopian    tube    and    blood    vessels    (Kelley). 


ALLOPIAN  TUBES  are  composed  of  the  muscular,  mucous  and 
submucous  coats,  lined  with  epithelium  and  covered  with  peri- 
toneum. The  circular  muscle  fibers  are  more  numerous  near 
the  uterus.  The  mucous  coat  is  covered  with  ciliated  epithelium, 
arranged  for  driving  the  contents  of  the  tube  toward  the  uterus 
with  which  the  epithelium  is  continuous,  and  extends  to  the  fim- 
briated end  of  the  tubes  where  they  join  the  peritoneum. 

Blood  vessels  are  from  the  uterine  artery  and  branches  of 
the  ovarian  artery  and  the  veins  connect  with  the  uterine  and 
ovarian  veins. 

Nerves  are  derived  from  the  plexus  that  supplies  the  ovary 
and  that  which  connects  with  the  uterus.  Afferent  fibers  appear 
to  belong  to  the  eleventh  and  twelfth  thoracic  and  the  first  lumbar 
nerves. 

The  lymphatics  join  the  lumbar  group  of  glands. 


ETIOLOGY. 


Ai 


Diseases  and  Injuries. 

Anomalies. 
Benign. 
Malignant. 
Injuries. 


D 


{ 


Page    One    Hundred    Sixteen 


ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
in  form,  size,  length,  relation  to  other  structures,  entrance  into  the  uterus,  blood,  nerve  and 
lymph  supplies,  or  one  or  both  entirely  absent  or  imperforate. 


DISEASES. 

Benign.     Malignant. 

BENIGN. 

Inflammation  may  be  primary  or  secondary,  acute  or  chronic,  local  or  general,  mild 
or  severe. 

Tuberculosis  may  be  primary  or  secondary,  local  or  general,  single  or  multiple,  acute 
or  chronic,  in  any  of  the  tissues  or  portion  of  the  tube,  become  arrested,  disappear  or  con- 
tinue to  destruction. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
local  or  general,  arrested,  disappear  spontaneously  or  continue  in  its  destruction. 

Papillomala  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  mul- 
tiple, with  or  without  pedicle,  in  any  portion  of  the  tube,  remain  quiescent,  disapp>ear  or 
continue  to  grow. 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
usually  without  pedicle,  in  any  portion  of  the  tube,  remain  quiescent,  continue  to  grow, 
or  disappear  spontaneously,  though  this  seldom  occurs. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape  and  location,  continue  to  grow,  remain  quiescent  or  disappear  spon- 
taneously. 

Pregnancies  may  be  primary  or  secondary,  single  or  multiple,  in  any  portion  of  the 
tube,  develop  to  about  the  sixth  week  before  which  time  they  invariably  rupture  to  escape 
into  the  peritoneal  cavity,  broad  ligament,  uterus,  bladder,  intestinal  canal,  rectum,  or 
vagina,  become  encysted  in  the  broad  ligament  where  they  may  die  and  remain  indefinitely 
or  develop  to  maturity,  and  then  die,  and  remain  indefinitely. 

Cysts  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  acute 
or  chronic,  vary  in  size,  contain  blood,  pus,  serum,  echinococci,  colloid  or  dermoid  ma- 
terial, rupture  into  the  broad  ligament,  peritoneal  cavity,  uterus,  bladder,  rectum,  vagina, 
perineum,  intestinal  tract  or  soft  tissues,  through  the  cutaneous  structures  anywhere  about 
the  pelvis. 

Fislulcs  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  open 
into  the  uterus,  peritoneal  cavity,  bladder,  vagina,  rectum,  perineum  or  through  the  ex- 
ternal soft  structures. 

Prolapse  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
behind  the  uterus,  into  the  vaginal  vault,  with  other  tissues,  or  complicated  with  various 
inguinal,  femoral  and  ventral  herniae  the  same  as  ovaries. 

MALIGNANT. 

Carcinomata  may  be  primary  or  secondary,  usually  primary,  in  any  portion  of  the 
tube,  unilateral  or  bilateral,  and  extend  into  the  broad  ligament,  uterus,  or  ovaries. 

Sarcomata  may  be  primary  or  secondary,  usually  primary,  single  or  multiple  in 
any  portion  of  the  tube,  unilateral  or  bilateral,  usually  unilateral. 

Page  One  Hundred  Seventeen 


INJURIES. 

Incisions,  punctures,  ruptures  may  be  primary  or  secondary,  single  or  multiple,  vary 
in  size  and  location,  by  accident  or  design,  complete  or  incomplete,  extend  into  th»v peri- 
toneal cavity,  uterus,  bladder,  rectum,  vagina,  or  the  overlying  soft  structures. 

Foreign  bodies,  though  small,  may  enter  the  Fallopian  tube  through  the  uterine 
canal,  the  w^all  of  the  tube  by  v^^ay  of  the  peritoneal  cavity,  the  rectum,  vagina,  or  through 
the  overlying  soft  structures. 

SYMPTOMS. 

Sy^mptoms  due  to  Fallopian  tube  disturbances  are  very  similar  in  character  to  those 
of  the  ovaries  and  uterus  because  of  their  close  proximity  and  intimate  relation  of  nerves. 
Their  similarity  is  so  great  that  instances  are  few  where  they  can  be  defined,  the  element 
of  doubt  always  existing. 

Local  tenderness  and  pain  are  the  earlier  manifestations  and  while  they  may  grad- 
ually increase  in  severity  until  the  general  manifestations  assert  themselves  they  are  not 
definite. 

Symptoms  are  alike  with  all  conditions  of  the  tubes  and  their  adjacent  structures  and 
for  this  reason  cannot  be  made  specific,  nor  can  they  be  differentiated  from  conditions  in 
their  adjacent  structures  except  in  a  few  instances  when  their  symptoms  predommate 


Page   One  Hundred  Eighteen 


CHAPTER  XXV. 


RECTUM 
ANATOMY. 


Fig.  57. — Pelvic  organs  seen   in   dissection   of   male  perineum    (Deaver). 


HE  RECTUM  is  seven  inches  long  and  extends  from  the  sigmoid 
to  the  external  sphincter  ani,  and  its  first  portion  ending  in  front 
of  the  tip  of  the  coccyx  and  bending  somewhat  backward.  In 
front  of  the  upper  portion  of  the  rectum  are  the  perineum,  blad- 
der, seminal  vesicles,  vasa  deferentia  emd  prostate  in  the  male 
and  vagina  in   the   female. 

The  second  portion  extends  from  the  tip  of  the  coccyx  and 
is  almost  entirely  encircled  by  the  internal  sphincter  am  muscle, 
and  not  covered  with  peritoneum.  The  distance  from  the  interna] 
sphincter  to  the  meso-sigmoid  is  four  inches. 

The  cylinder  in  the  upper  portion  though  about  two  inches 
in  diameter  may  be  distended  to  four  or  five  inches  with  feces 
or  the  hand  without  rupture. 

External  sphincter  ani  muscle  arises  from  the  coccyx  and 
extends  to  the  anus,  sometimes  to  the  bulbocavernosi  muscle.      It 


Page  One  Hundred  Nineteen 


is  composed  of  striated  fibers  which  lie  directly  beneath  the  skin  and  its  purpose  is  to  open 
and  close  the  anal  orifice  and  to  fix  the  anterior  tendon  of  the  perineum  during  contraction 
of  the  bulbocavernosi,  some  fibers  completely  surrounding  the  anus.  In  the  female  a  few 
decussate  with  those  of  the  sphincter  vaginae  and  nearer  the  outside  circles  than  the  internal 
sphincter.  The  anterior  fibers  pass  along  the  sides  of  the  prostate  and  vagina.  The  middle 
fibers  blend  with  the  longitudinal  fibers  of  the  rectum  and  extend  to  the  sphincter  ani  and 
the  posterior  fibers  join  the  other  lavatori  to  become  inserted  at  the  tip  of  the  coccyx. 

Blood  supply  is  the  superficial  perineal  artery  which  is  a  branch  of  the  internal  pudic, 
given  off  just  before  it  enters  the  space  between  the  layers  of  the  triangular  ligament  of 
the  perineum.     It  is  sometimes  termed  the  transverse  artery  of  the  perineum. 

The  fourth  sacral  and  inferior  hemorrhoidal  nerves  supply  the  external  sphincter  ani 
muscle.  Some  fibers  coming  from  the  pudic  and  inferior  mesenteric  and  pelvic  plexuses, 
arise  from  the  fourth  sacral  and  inferior  hemorrhoidal  branch  of  the  pudic  and  they  in 
turn  connect  with  the  small  sciatic,  pudic  and  fourth  sacral  nerves. 

The  inferior  hemorrhoidal  nerve  usually  branches  off  the  pudic  after  it  peisses  through 
the  lesser  sacro-sciatic  foramen  and  supplies  the  external  sphincter,  cutaneous  filaments  to 
the  perineal  integument  and  communicating  branches  of  the  inferior  pudendal  and  super- 
ficial nerves. 

It  is  thus  seen  that  it  has  three  important  branches,  the  inferior  hemorrhoidal,  perineal 
and  dorsal  nerve  of  the  penis  and  clitoris,  the  main  trunk  having  passed  forward  in  Al- 
cock's  canal  in  the  obturator  fascia.  With  the  change  from  cloacal  to  the  true  mammalian 
condition,  the  pudic  trunk  was  necessarily  split  into  many  twigs,  it  no  longer  answering  the 
purpose  for  which  it  was  first  intended. 

Levator  ani  muscle  is  composed  of  three  sets  of  fibers. 

Anterior,  pass  along  the  side  of  the  prostate  and  vagina. 

Middle,  blend  with  the  longitudinal  fibers  of  the  rectum  and  extends  to  the  sphincter 
ani. 

Posterior,  join  the  other  levator  ani  to  be  inserted  into  the  tip  of  the  coccyx.  The 
entire  muscle  is  supplied  by  the  inferior  hemorrhoidal  and  fourth  and  fifth  sacral  nerve, 
and  its  function  is  to  raise  the  pelvic  floor  and  fascia. 

Blood  Supply.  The  levator  ani,  obturator  internus,  pyriformis  and  coccygeus  mus- 
cles are  in  part  supplied  by  the  gluteal.  The  pyriformis  and  coccygeus  also  receive 
tranches  from  the  lateral  sacral  artery.  The  sciatic  artery  also  sends  branches  to  the 
pyriformis,  levator  ani  and  coccygeus  muscles,  and  the  obturator  receives  a  branch  from 
the  internal  pudic  artery. 

The  recto  vesical  fascia's  principal  function  is  to  prevent  pus  and  extravasated  urine 
from  passing  from  the  perineum  to  the  pelvis. 

Blood  supply  of  the  rectum  is  from  three  hemorrhoidal  and  middle  sacral  arteries, 
the  m.ost  important  of  which  is  the  superior  hemorrhoidal,  which  is  the  prolongation  of  the 
inferior  messenteric  trunk,  which  after  reaching  the  rectum  from  the  meso-colonic  root, 
divides  into  two  chief  branches  which  course  around  the  sides  of  the  rectum  anteriorly. 
Many  of  its  small  branches  then  perforate  the  rectal  muscular  fibers  to  supply  their 
mucous  membrane.  The  superior  and  middle  hemorrhoidal  anastomose  both  externally 
and  internally  to  the  rectal  wall. 

The  inferior  hemorrhoidal  artery  pierces  the  inner  wall  of  Alcock's  canal,  and  runs 
obliquely  forward  and  inwards.  It  soon  divides  into  two  or  three  main  branches,  which 
sometimes  arise  separately  and  pass  across  the  space  to  the  anal  passage.  The  artery 
anastomoses  in  the  walls  of  the  anal  passage  with  its  fellow  on  the  opposite  side  and  with 
the  middle  and  superior  hemorrhoidal  arteries.  It  also  anastomoses  with  the  transverse 
perineal  arteries  and  supplies  cutaneous  twigs  to  the  region  of  the  anus,  and  others  turn 
around  the  border  of  the  gluteus  maxims  to  supply  the  lower  part  of  the  buttock. 

Nerve  supply  is  from  the  sympathetic  twigs  which  are  derived  from  the  inferior  mes- 
senteric and  hypogastric  (sometimes  called  pelvic  plexus)  and  cerebrospinal  system,  fibers 
of  which  arise  from  the  second,  third  and  fourth  sacral  nerves.  Fibers  of  the  inferior 
hemorrhoidal  branch  of  the  internal  pudic  nerve   (third  and  fourth  sacral)    are  also  dis- 

Page    One    Hundred    Twenty 


tributed  to  the  lower  part  of  the  anal  canal  and  external  sphincter.  The  second,  third  and 
fourth  sacral  nerves  convey  motor  impulses  to  the  longitudinal  fibers  but  also  inhibits  im- 
pulses to  the  circular  muscular  fibers. 

Fibers  from  the  sympathetic  also  convey  motor  impulses  to  the  circular  muscle  and 
inhibitory  fibers  to  the  longitudinal  muscles  of  the  rectum. 

The  reflex  center  which  governs  the  action  of  the  sphincter  and  the  muscular  fibers 
of  the  rectum  (defecation  center)  is  situated  m  the  lumbar  region  of  the  cord  and  appears 
to  be  capable  of  carrying  out  the  whole  act  of  defecation  even  when  separated  from  the 
brain. 

Lymphatics  of  the  rectum  pass  to  the  glands  on  the  front  of  the  sacrum  and  some  in 
the  lower  portion  of  the  anal  canal  join  the  lymphatics  around  the  anus  and  pass  with 
them  to  the  oblique  set  of  the  superficial  inguinal  glands,  a  few  from  the  lower  portion  of 
the  rectum  are  said  (Quenu)  to  jom  the  iliac  glands  but  these  are  not  constant  according 
to  Gerota. 

ETIOLOGY. 

Anomalies,  Diseases  and  Injuries. 

Anomalies. 

Dr    Benign, 
iseases    -      i\  ^r   i  • 

(     Malignant. 

Injuries. 

ANOMALIES. 

Anomalies  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
in  any  portion,  vary  in  length,  diameter  and  uniformity  of  lumen,  position  and  relation  to 
other  structures,  a  part  or  all  of  the  rectum  absent,  and  the  anal  opening  behind,  in  the 
vagina,  bladder,  urethra,  uterus,  peritoneal  cavity  or  absent. 


DISEASES. 

Benign.      Malignant. 
BENIGN. 

Benign  diseases  are  of  many  kinds  and  varieties  and  may  occupy  any  portion  of 
the  cylinder.     They  may  be  congenital  or  acquired  and  vary  in  size  and  rate  of  growth. 

Proctitis  may  be  primary  or  secondary,  acute  or  chronic,  local  or  general,  mild  or 
severe. 

Ulcers  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  result  from  infection  or  pressure,  necrosis,  extend  partially  or  completely 
through  any  portion  of  the  rectal  wall  especially  in  the  lower  third  of  the  cylinder. 

Fissures  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  sin- 
gle or  multiple,  vary  in  depth,  length  and  width  in  one  or  all  of  the  tissues  of  the  wall, 
location,  almost  invariably  external  or  between  the  sphincters.  Their  most  frequent  cause 
is  the  passage  of  such  a  mass  through  one  of  normal  tension,  or  the  presence  of  cicatricial 
tissue. 

Fistulce  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single 
or  multiple,  extend  into  and  through  the  perineum,  posterior  soft  structures,  urethra,  blad- 
der, prostate,  vagina,  uterus,  or  peritoneal  cavity,  vary  in  size,  length  and  location,  straight 
or  tortuous. 

Page    One    Huiulivil    T\vent\-One 


Varicosities  such  as  hemorrhoids,  angiomata  and  aneurysms  may  be  congenital  or  ac- 
quired, primary  or  secondary,  acute  or  chronic,  in  one  or  more  vessels  or  any  portion  of 
the  rectum,  vary  in  size  and  sometimes  disappear  spontaneously.  ^ 

Papillomata  are  of  the  more  common  varieties  found  within  the  rectum  and  they 
may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  usually  multiple, 
located  anywhere  upon  the  mucous  membrane  and  develop  to  a  considerable  size,  usually 
with  pedicle.  (See  Papillomata  and  Adenomata  of  the  Rectum,  A^.  Y.  Med.  Jour., 
Vol.  LXXX,  1907,  also  Papillomata  and  Adenomata,  Hist.  Review,  Amer.  Jour. 
OF  Dermatology,  March  1,  1908.     (Ricketts.) 

Adenomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
upon  any  portion  of  the  inner  surface  of  the  rectum,  vary  in  size  and  shape,  remain  quies- 
cent, continue  to  grow  or  disappear  spontaneously.  They  usually  have  a  broad  base  and 
appear  most  frequently  in  the  lower  half  of  the  cylinder. 

Tuberculosis  may  be  primary  or  secondary,  acute  or  chronic,  single  or  multiple,  vary 
in  size,  be  upon  any  portion  and  in  any  tissue,  but  usually  in  the  lower  third  of  the  cylinder 
and  extend  into  the  surrounding  tissues. 

Syphilis  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
single  or  multiple,  vary  in  size,  in  amy  tissue  or  location  and  usually  in  the  lower  third 
of  the  cylinder,  sometimes  disappears  spontaneously  or  cause  total  destruction  of  any  part 
or  all  of  the  rectal  wall  in  the  form  of  gumma. 

Fibromata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape,  location,  in  any  tissue,  usually  in  the  lower  half  of  the  cylinder. 

Lipomata  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple, 
vary  in  size,  shape,  location,  in  any  tissue  but  usually  about  the  middle  of  the  cylinder. 

Prolapsus  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  one 
of  four  degrees.  Hyperexertion  to  stool  when  the  lumen  of  the  rectum  has  been  lessened 
by  any  cause  and  when  the  sphincters  have  relaxed  unduly  are  the  most  common  causes. 

Infection  may  be  primary  or  secondary,  bacterial  or  parasitic,  local  or  general,  mild  or 
severe,  acute  or  chronic,  and  result  in  abscess  within  the  rectal  wall  or  any  of  the  adjacent 
tissues  or  organs. 

Cyds  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic,  single  or 
multiple,  in  any  portion  or  tissue,  contain  blood,  pus,  serum,  echinococci  or  dermoid  ma- 
terial, rupture  posteriorly  through  the  soft  structures,  into  the  vagina,  rectum,  perineum, 
urethra,  uterus  or  peritoneal  cavity. 

Strictures  may  be  congenital  or  acquired,  primary  or  secondary,  acute  or  chronic, 
partial  or  complete,  single  or  multiple,  in  any  portion  of  the  rectal  wall. 

Parasites  may  be  congenital  or  acquired,  primary  or  secondary,  single  or  multiple,  re- 
main indefinitely  with  or  without  producing  inflammation,  encysted  or  within  the  open  cavity. 

Foreign  bodies  may  enter  from  without  or  within,  through  the  anus  or  mouth,  vagina, 
bladder,  uterus,  peritoneal  cavity  or  external  soft  structures. 

Feces  may  be  hard  or  soft  in  consistency  and  either  form  cause  great  rectal  or  con- 
stitutional disturbances.  If  the  normal  diameter  of  a  mass  normal  in  consistency,  is  less- 
ened from  any  cause  at  a  given  point  distant  to  the  sphincters,  the  pressure  upon  them  will 
not  be  normal  in  uniformity  or  degree  because  the  line  of  perpendicular  will  have  been 
changed.  Thin  or  watery  stools  are  probably  exceptions  to  this  rule  and  an  empty  gut 
significant  of  quietude. 

These  remarks  apply  to  both  sexes  but  because  of  the  difference  in.  their  anatomical 
relations  the  same  rules  for  classification  do  not  obtain.  In  the  male  the  fecal  mass  is 
pushed  forward  against  the  prostate,  seminal  ducts  and  urethra  while  in  the  female  this 
force  is  forward  against  the  vaginal  wall  and  uterus. 

MALIGNANT. 

Malignant  diseases  are  of  two  kinds  with  their  respective  variations.  Those  sar- 
comatous in  character  are  less  frequent  and  usually  of  secondary  origin.  The  carcinomata 
are  more  common  eind  as  a  rule  primary  in  origin.      Either  variety  may  occur  upon  any 

Page   One   Hundred   Twenty-Two 


portion  of  the  rectal  wall  or  mucous  membrane,  always  smgle  and  more  frequent  m  the 
lower  half  of  the  rectum  and  more  often  in  the  male  in  whom  ulcer  is  more  common. 

Carcinomala  may  be  primary  or  secondary,  single  or  multiple,  in  any  tissue  or  portion 
of  the  rectum,  usually  single,  and  appear  most  frequently  on  the  mucous  membrane  imme- 
diately overlying  the  tip  of  the  coccyx. 

Sarcomata  may  be  primary  or  secondary,  single  or  multiple,  usually  single,  in  any 
tissue  or  portion  of  the  rectal  wall. 

INJURIES. 

Ruptures. 

Laceration. 

Incision. 

Puncture. 

Rupture  of  the  rectum  may  assume  one  of  three  varieties,  laceration,  incision  and 
puncture  and  each  vary  in  extent,  number  and  position,  partial  or  complete,  through  the 
rectal  wall  or  when  complete,  extend  into  the  surrounding  soft  structures,  vagina,  uterus, 
bladder,  peritoneal  cavity,  urethra,  seminal  vesicles  or  prostate. 

SYMPTOMS. 

Rectal  Reflexes  and  Neuroses.      (By  H.  C.  Von  Dahm,  M.  D.) 

The  consideration  of  rectal  reflexes  and  neuroses  leads  to  anatomical  fields  sometimes 
far  removed  from  the  rectum,  and  again  to  fields  so  intimately  associated  with  that  organ, 
not  only  anatomically,  but  from  symptomatic  and  pathologic  standpoints,  that  the  subject 
becomes  a  vast  one  and  of  no  little  importance. 

The  close  association  of  the  rectum  with  the  genito-urmary  system  makes  the  success- 
ful study  of  either  one  necessarily  lead  to  a  consideration  of  the  other.  Especially  is  this 
true  as  to  the  neurotic  manifestations  of  their  pathology. 

A  review  of  the  nerve  supply  of  the  rectum  shows  its  innervation  derived  from  both 
the  sympathetic  and  spinal  systems  with  a  predomination  of  the  sympathetic. 

This  system  supplies  numerous  filaments  from  the  hypogastric,  sacral  and  mesenteric 
plexes,  while  the  spinal  element  is  derived  from  the  third,  fourth  and  fifth  sacral  nerves.  In 
their  distribution  the  two  nerve  elements  become  intimately  interwoven.  The  spinal  nerves 
in  their  course  to  the  rectum,  pass  through  the  sacral  plexus  of  the  sympathetic  and  are  dis- 
tributed to  the  striated  muscles,  the  levator  ani  and  external  sphincter,  thence  to  the  peri- 
neal skin  and  the  modified  epithelium  of  the  anorectal  region  as  far  up  as  the  anorectal 
line.  Above  this  line  we  find  only  sympathetic  distribution,  the  voluntary  control  of  the 
rectal  function  ceases  and  becomes  an  automatic  one,  entirely  under  the  control  of  the 
sympathetic. 

The  perineum,  prostate,  urethra,  bladder  and  vagina  receive  a  great  part  of  their 
spinal  and  sympathetic  nerve  supply  from  the  same  source  as  the  rectum  and  anus,  \\'hich 
fact  accounts  for  the  various  reflexes  between  the  rectal  and  genito-urinary  systems.  Any 
pathological  condition  of  the  rectum  may  give  rise  to  genito-urinary  symptoms,  while  many 
times  genito-urinary  lesions  have  their  symptoms  referred  to  the  rectum. 

This  rule  obtains  with  both  sexes  though  more  frequently  and  numerous  in  the  male 
and  of  a  more  severe  and  complicated  character  because  the  genito-urinary  system  of  the 
female  is  less  complicated  in  its  arrangement. 

Rectal  disturbances  are  factors  that  always  necessitate  consideration,  especially  when 
the  male  reproduction  organs  are  disturbed.  They  are  so  intimately  associated  and  com- 
plex, that  it  is  often  impossible  to  discover  their  cause  or  origin,  but  such  a  difficulty  is 
not  so  likely  to  be  encountered  when  the  rectum  in  the  female  is  primaiily  disturbed,  because 
for  want  of  so  close  a  proximity  of  the  two  tracts  as  exists  in  the  male.  The  same  might 
he  said  about  the  urinary  apparatus  in  the  female  because  of  the  absence  of  complexity. 

While  symptoms  of  rectal  conditions  are  quite  significant,  those  of  the  sigmoid  are 
intimately  associated  because  their  distinction  is  but  imaginary,  one  being  an  extension  of 
the  other. 

Page  One  Huiulred  Twenty-Throe 


From  the  studies  of  various  investigators  and  anatomists,  we  draw  the  conclusion  (a) 
that  the  innervation  of  the  pelvic  viscera  is  derived  chiefly  from  the  sympathetic  or  is 
greatly  controlled  by  it.  <!v 

(b)  That  the  innervation  for  both  automatic  rectal  and  automatic  vesical  function 
is  situated  entirely  in  the  sympathetic ; 

(c)  That  the  spinal  cord  in  its  relation  to  the  pelvic  viscera  is  simply  the  pathway 
for  sensory)  impulses  to  the  brain  and  for  cerebral  impulses  controlling  their  voluntary 
functions. 

(d)  That  the  two  systems  are  intimately  joined  by  the  rami-communicantes  of  the 
lumbar  and  sacral  segments  of  the  cord. 

Only  by  the  consideration  of  these  facts,  are  we  able  to  grasp  the  far-reaching  but 
withal  closely  related  reflexes  and  neuroses  of  the  pelvic  viscera. 

Rectal  reflexes  may  arise  from  (a)  areas  innervated  by  the  spinal  nerves,  (b)  by 
the  sympathetic,  or  (c)  by  both  systems. 

The  close  association  of  the  two  systems  often  makes  it  impossible  to  definitely  state 
that  a  reflex  arises  entirely  from  one  system  or  the  other.  Generally  speaking,  however, 
we  may  say  that  the  spinal  factor  is  represented  in  all  areas  where  stimuli  can  be  recognized 
and  localized  by  the  patient,  while  the  sympathetic  factor  may  affect  distant  points,  the  local 
stimulus  not  being  recognized  except  as  referred  pain  at  some  point  of  spinal  distribution. 

We  may  conclude,  therefore,  that  these  reflexes  may  be  manifested  by  (a)  motor 
spasms,  (b)  by  sensory  disturbances,  (c)  by  alterations  in  secretion  or  (d)  by  any  com- 
bination of  these  three  results. 

The  most  familiar  rectal  reflex  and  the  most  neglected  one  is  that  of  defecation.  Here 
we  have  the  motor  element  represented  by  the  contraction  and  relaxation  of  the  striated 
muscles  of  the  pelvis  and  the  abdominal  muscles;  the  sensor]^  disturbance  manifested  by 
peripheral  nerve  stimulation  at  the  anal  papillae  from  contact  -with  the  feces ;  and  the 
secretory  element  by  a  further  secretion  by  the  rectal  mucosa.  The  desire  for  stool  comes 
on  when  pressure  on  the  muscular  coats  of  the  rectum,  on  the  levator  ami  and  pelvic  wall 
creates  a  sense  of  fullness;  this  is  sent  to  the  sympathetic  ganglia  as  an  afferent  impulse,  is 
returned  as  a  strong  efferent  impulse  and  causes  contraction  of  the  involuntary  muscles  of 
the  rectum. 

In  addition  to  this  impulse  another  is  created  at  the  anal  papillce.  by  the  mass  coming 
in  contact  with  their  extremely  sensitive  surfaces.  This  generates  the  motor  impulse  and  the 
voluntary  muscles  do  their  part.  This  short  reflex  would  result  in  automatic  evacuation 
were  it  not  overcome  by  the  voluntary  contraction  of  the  external  sphincter  and  levator  ani 
muscles.  The  reflex  is  kept  up  however,  to  exhaustion,  and  as  it  becomes  exhausted,  the 
desire  passes.  Neglect  of  this  reflex  demand  of  nature,  we  know  is  one  of  the  basic  causes 
of  so-called  "habit"'  constipation. 

As  said  before,  were  it  not  for  the  po\ver  of  voluntary  inhibition,  the  act  of  defeca- 
tion would  be  entirely  automatic,  the  rectum  emptying  itself  as  soon  as  the  efferent  sym- 
pathetic impulses  were  of  sufficient  strength  to  generate  motor  impulses.  In  addition  to 
this  automatic  power  the  rectum  exhibits  a  marked  tendency  to  periodicity  in  the  exercise 
of  its  function. 

If  inhibition  of  the  efferent  motor  impulse  is  the  basic  cause  of  "habit''  constipation, 
here  then  we  have  the  simplest  cure.  Coincide  with  the  reflex  of  automaticity  and  peri- 
odicity, thus  creating  a  "habit  action'  and  the  "habit  constipation"  is  removed.  This, 
of  course,  is  true  only  when  the  reflex  arc  is  unimpaired  by  lesions  of  its  centers. 

Anal  fissure  is  a  condition  giving  rise  to  many  neuroses.  There  is  at  first  a  spinal 
reflex  evidenced  by  the  contraction  of  the  external  sphincter  at  the  time  of  defecation  or 
upon  digital  examination.  (The  spasm  is  much  more  marked  than  the  simple  anal  reflex 
— this  latter,  after  a  short  time,  becoming  much  accentuated) .  Later  when  the  irritation 
from  the  fissure  becomes  more  severe  a  mixed  reflex  is  developed,  with  much  pain  either  at 
the  time  of  stool  or  immediately  following.  This  causes  an  involuntary  reflex  contraction 
of  the  sphincter,  which  cannot  be  voluntarily  relaxed.  We  must  remember  that  the  ex- 
ternal sphincter  must  be  relaxed  reflexly,  but  that  it  may  be  contracted  both  reflexly  and 
voluntarily. 

Paffe  One  Hundred   Twenty-Four 


The  spasmodic  contraction  of  the  sphincter  so  depletes  the  blood  supply  of  the  fissure 
and  irritates  the  exposed  nerve  endings  to  such  a  degree  that  reverse  reflexes  are  set  up. 
The  pain  may  now  be  referred  to  the  sacrum,  prostate,  the  ovaries  or  the  bladder.  It  may 
even  travel  down  the  thigh,  or  follow  the  distribution  of  the  fourth  and  fifth  sacral  nerves. 
Intestinal  disturbances  may  arise  such  as  flatulence,  or  vague  diffuse  pain.  These  reflexes 
may  be  explained  as  may  all  complex  neuroses  of  this  region  by  the  contiguity  of  their 
spinal  and  sympathetic  centers.     A  thrombotic  hemorrhoid  may  give  rise  to  similar  symptoms. 

One  of  the  common  reflexes  of  internal  hemorrhoids  is  a  pain  and  sense  of  rvcight 
in  the  floor  of  the  pelvis,  or  sometimes  it  is  referred  to  the  sacrum.  This  may  be  explained, 
as  the  result  of  the  congested  rectum  pressing  upon  the  levator  ani  muscles  or  upon  one 
of  the  nearby  sacral  nerves. 

Anal  pruritus  gives  rise  to  a  number  of  neuroses,  of  which  itching  is  the  most  promi- 
nent. This  reflex  is  observed  in  the  perineal  skin  and  in  the  modified  skin  lining  the  anal 
canal  as  far  up  as  the  crypts.  This  symptom  is  due  to  irritation  of  those  nerves  capable 
of  carrying  tactile  sensation  and  not  those  which  convey  painful  stimuli.  Local  anes- 
thetics will  neutralize  painful  skin  sensations  in  this  region  but  will  not  stop  the  itching  of  a 
true  pruritus.  Another  neurosis  in  this  condition  is  a  sensation  of  crarvling.  This  is  due 
to  irritation  of  the  same  nerve  endings.  An  illustration  of  the  secretor])  f^pe  of  reflex  some- 
times present  in  anal  pruritus  is  perineal  sweating.  This  symptom  has  also  been  noted  in 
cases  of  great  nervous  excitement  and  in  fecal  impaction. 

Ordinarily,  sensations  of  moisture  or  dryness  are  felt  only  in  the  anal  and  perineal 
skin.  However,  when  the  pathology  causing  these  conditions  is  situated  either  in  the  rectal 
ampulla  or  at  the  anorectal  line,  the  sensation  to  the  patient  is  at  the  point  of  irritation 
and  not  where  the  moisure  or  dryness  exists. 

A  cryptitis  may  produce  more  disturbances  of  spinal  sensation  and  motor  function 
than  any  other  rectal  lesion.  The  resulting  neuroses  are  legion  and  may  be  explained  by 
the  complicated  and  interwoven  nerve  supply  to  the  crypts  and  to  the  papillae  in  immediate 
relationship.  So  profound  does  this  irritation  become  that  a  mental  exhaustion  or  extreme 
emotional  irritability  has  been  noted  and  from  no  other  cause. 

Persistent  vomiting  is  a  neurosis,  which  may  result  from  impacted  feces  in  the  rectum 
or  colon.  Retained  flatus,  tumors  and  strictures  of  the  rectum,  especially  when  they  are 
high  enough  to  press  upon  the  peritoneum,  may  give  rise  to  pain  which  may  be  referred  to 
the  appendix,  the  bladder  or  ovaries. 

Lesions  above  the  ano-rectal  line  are  not  so  liable  to  cause  so  many  complicated 
neuroses  as  are  those  situated  belorv  this  highly  sensitized  region.  This  is  true  also  of 
extra-rectal  lesions  involving  the  loose  tissue  immediately  around  that  organ.  It  has  been 
a  much  discussed  question,  if  the  mucosa  of  the  rectum  proper  is  at  all  supplied  with 
sensory  nerve  endings.  It  has  been  demonstrated  that  ulcers  may  be  cauterized  without 
localized  pain  to  the  patient;  that  hemorrhoids  may  be  removed  without  an  anesthestic  and 
that  sensations  of  heat  and  cold  cannot  be  detected  unless  they  come  in  contact  with  the 
spinal  innervation  at  the  ano-rectal  line.  Carcinoma  of  the  rectum  develops  no  pain  that 
can  be  localized  until  it  involves  the  voluntary  muscles  of  the  pelvis  or  pelvic  wall.  This 
may  be  why  so  many  rectal  carcinomas  reach  an  inoperable  stage  before  their  presence  is 
discovered.  This  absence  of  localized  pain  is  noted  also  in  suppurations  outside  the  rec- 
tum. Unless  they  involve  some  one  of  the  structures  named  or  press  upon  a  nerve  fila- 
ment their  presence  is  often  unsuspected. 

There  are  a  number  of  neuroses  that  occur  without  the  presence  of  pathology  in 
tissue.  A  patient  may  complain  of  vagus  symptoms  of  uneasiness  or  pain  in  the  region  of 
the  anus  and  upon  examination  we  find  everything  normal.  Perhaps  a  few  minutes  later 
another  examination  \vi\\  disclose  a  sphincter  in  the  extreme  spasm.  We  must  necessarily 
account  for  this  as  pain  due  to  muscular  contraction  from  some  central  lesion  and  not  to 
peripheral  irritation.  This  may  in  time  produce  marked  systemic  and  mental  phenomena. 
Or  on  the  contrary,  undue  sphincteric  dilation  may  produce  phenomena  just  as  profound. 
It  is  not  uncommon  in  highly  sensitive  individuals  to  find  a  condition  bordering  on  nervous 
exhaustion  following  a  constipated  stool.  The  systemic  effect  of  divulsion  of  the  sphinc- 
ters is  very  evident.     The  heart  action  is  increased,  blood  pressure  is  raised,  the  respirations 

Page   One   Hundred   Twenty-Five 


become  deeper,  the  capillaries  are  flushed  through  excitation  of  the  vaso-motor  center  and 
profound  nervous  phenomena  are  produced. 

Following  divulsion  of  the  sphincters,  we  sometimes  find  the  internal  sphincter  in  a 
state  of  contraction  and  doing  the  work  of  both.  Sahli  calls  this  condition  "vicarious  con- 
traction," while  Cook  gives  it  the  name  of  "compensatory  contraction."  It  may  be  ex- 
plained by  the  voluntary  contraction  of  the  levator  ani  and  glutei  stimulating  a  sympathetic 
reflex  which  is  referred  to  the  internal  sphincter. 

In  a  consideration  of  neuroses  of  the  rectum,  we  must  differentiate  between  diseases 
of  that  organ  with  referred  pain  in  extra  rectal  structures  and  pathological  conditions,  which 
are  extra  rectal,  but  producing  rectal  symptoms.  In  addition  to  their  local  symptoms, 
peculiar  to  the  lesion,  prostatitis,  seminal-vesiculitis,  urethral  stricture,  various  lesions  of  the 
bladder,  renal  calculi,  and  ovarian  or  uterine  inflammations  may  exhibit  a  very  marked  pain 
in  the  rectum  or  sacrum.  These  symptoms  are  often  ascribed  to  some  slight  rectal  lesion 
and  the  real  cause  overlooked.  Especially  is  this  true  of  uterine  or  ovarian  displacement. 
Illustrative  of  this,  a  retroverted  uterus  may  produce  a  mucoid  proctitis  or  hemorrhoids. 
Treatment  of  these  conditions  would  afford  only  temporary  relief  at  best  while  correction 
of  the  displacement  would  bring  about  permanent  benefit. 

Lesions  of  the  central  nei-vous  system,  which  interfere  with  the  transmission  of  motor 
or  sensory  impulses  are  often  exhibited  in  the  rectum.  AUingham  says:  "In  the  beginning 
of  various  forms  of  mania  one  often  observes  that  the  patient  has  severe  pains  in  the  rectum 
without  any  pathological  lesion  to  account  for  the  same/'  Locomotor  ataxia  shows  ear/jj 
rectal  symptoms  such  as  constipation,  paroxysmal  pain,  lessened  irritability  of  the  sphmcters 
and  loss  of  sensation  in  the  perineal  skin.  Later  we  may  have  a  loss  of  the  voluntary 
or  reflex  control  of  the  bowel.  When  this  last  occurs,  a  vicarious  condition  is  produced, 
as  the  automatic  control  is  not  lost  so  early,  and  we  have  a  constipation  with  incontinence. 
Acute  transverse  myelitis  results  in  early  paralysis  of  the  rectum  and  bladder,  while  in  the 
lateral  sclerosis,  we  observe  increased  sphincteric  rigidity  and  reflexes. 

A  review,  such  as  this  paper  is  intended  to  be,  would  be  far  from  complete  without 
a  reference  to  the  effect  of  rectal  pathology  on  the  general  health  of  the  individual.  There 
is  hardly  a  lesion  of  the  rectum  that  does  not  have  its  effect  on  the  general  nutrition.  Many 
of  them  go  farther  and  make  their  influence  felt  on  the  mind  as  well.  Especially  is  this 
true  in  individuals  of  a  nervous  temperament.  It  is  surprising  the  amount  of  mental  relief 
afforded  by  a  successful  treatment  or  operation  upon  a  rectal  lesion.  Whether  the  con- 
dition before  treatment  v/as  psychical  or  physical,  the  feeling  of  depression  is  thrown  off 
and  the  patient  is  afforded  mental  and  physical  relief  sometimes  out  of  all  proportion  to  the 
pathology  removed. 

A  rectum  distended  with  gas  or  feces  may  cause  painful  disturbances  alike  through- 
out  the  uro-genital  and  rectal  tracts,  because  of  the  excessive  pressure  upon  the  seminal 
vesicles  and  prostate  glands,  so  rich  in  sensory  nerve  filaments. 

Highly  acidulated  feces  or  a  bladder  distended  wth  urine,  or  containing  a  highly 
acid  urine,  will  cause  the  desire  to  urinate,  defecate  or  copulate.  Constipation  and  diar- 
rhea may  be  the  result  of  such  a  condition  and  is,  no  doubt,  frequently  the  cause  of  the 
uterus  discharging  prematurely  its  fetal  contents. 

Rectal  irritation  in  certain  individuals  of  either  sex,  may  produce  greater  sexual  ex- 
citability thaui  the  same  degree  of  irritation  to  the  sexual  organs  alone,  and  irritation  of 
the  sexual  organs  may  cause  a  desire  to  defecate  and  irritation  to  either  may  cause  frequent 
desire  to  urinate,  thus  demonstrating  the  intimate  relationship  of  their  nervous  impulses  in 
both  health  and  disease. 

It  may  cause  the  loss  or  increase  of  sexual  desire  and  sometimes  be  associated  with 
dull  pain  of  a  bearing-down  character,  which  is  so  frequently  reflected  to  the  coccyx  and 
pain  in  the  loin  about  the  buttocks  and  sometimes  down  the  thigh. 

Alimentary  function  may  remain  normal  or  be  disturbed  by  the  various  rectal  condi- 
tions and  their  compHcations  in  the  form  of  nausea,  vomiting,  eructation,  acid  stomach, 
flatulence,  constipation,  diarrhea  and  distention. 

They  may  be  mild  or  severe  or  of  short  or  long  duration. 

The  appetite  may  be  impaired  by  infection  due  to  any  cause  and  its  impairment  in- 
creases with  the  degree  of  infection  or  irritability. 

Page    One    Hundred    Twenty-Six 


CHAPTER  XXVI. 


PERSONAL  BIOGRAPHY. 

1.  The    Negligence   and    Result  of   Vaccination,    Iionton,   O.,   June    1,    1882    (pamphlet). 

2.  Lynx  Rufus,  Journal  Cincinnati  Nat.  Hist.  Soc,  April,  1882. 

3.  Construction   of   Sewers,    Ironton,   O.,   June,    1882,    (pamphlet). 

4.  A  Case  of  Scarlatina,   Med.  Soc.  Columbus,   O.,   Col.  .Med.  Journal,   January,    1884. 

5.  Internal   Urethrotomy,   January   2,    1893,   p.    195,    Bound,   Vol.   5. 

6.  A  Case  of  Ichthyosis  Sebacea,  Lancei-Clinic,  Cincinnati,   1885,  x,  p.  312. 

7.  Clinical    Use   of   Chrysarobin.      Lancet-Clinic,    Cincinnati,    1885,    xiv,    312. 

8.  Pityriasis    Rosea,    Lancet-Clinic,    Cincinnati,    1885. 

9.  A  Case  of   Lichen   Scrofulosis.      Lancet-Clinic,   Cincinnati,    1885,   x,   p.   427. 

10.  Pyrogallic   Acid,    Its    Preparation   and   Uses.      Lancet-Clinic,    Cincinnati,    1885,   x,   p.   39. 

11.  Three    Cases   of   Carcinoma.      Lancet-Clinic,   Cincinnati,    1885,    x,    p.    398. 

12.  Case  of   Epithelioma   Monographia  Syphilitica,    1885. 

13.  Lupus  Vulgaris,  Columbus   (O.)    Med.  Journal,   May,    1885. 

14.  Treatment  of  Ulcer   (Chronic)   Leg,   Virginia  Med.  Monthly,   1885. 

15.  Cincinnati  Med.  Soc.  Discussion  Plastic  Surgery.     Lancei-Clinic,  Cincinnati,  March  23,   1886. 

16.  -Abscess  Cerebellum   (Case  Specimen).     Lancet-Clinic,  Cincinnati  May  4,    1886. 

17.  Sponge   Grafting.      Lancet-Clinic,   Cincinnati,   April    13,    1886. 

18.  Epithelioma- Aetology,    Diagnosis   and    Treatment.      Lancei-Clinic,    Cincinnati,    June    12,    1886. 

19.  Thermocautery    in   Treatment   of   Herpes.      Lancet-Clinic,   Cincinnati,    October    13,    1886. 

20.  A  Case   of   Morphia.      Cincinnati  Med.  Journal,   Sept.,    1886. 

21.  Psoriasis.  Lancet-Clinic,  Cincinnati,  xviii,  p.  265,   1887. 

22.  Onochogriphosis.      Lancet-Clinic,    Cincinnati,    xviii.    p.    303,    1887. 

23.  Rodent  Ulcer,  Papillomatous  Epithelioma  and  Lupus  Eiythematosis,  Lancel-Climc,  Cincinnati, 
March,    1887. 

24.  Oidium  Albicans.     Lancea-Clinic,   Cincinnati,   xviu,  p.   393,    1887. 

25.  Management  of  Eczema.     Lancei-Clinic,  Cincinnati,  July  30,   1887. 

26.  Urticaria    (Copaiba).      Lancei-Clinic,    Cincinnati,    Dec.    19,    1887. 

27.  The  Relation  of  the  Red  Corpuscles  to  the   Brain.     Jour.  Nat.  Hist.  Soc,   Cincinnati,  April, 

1887. 

28.  Surgical   Treatment   of   Tubercular   Glands.      Cincinnati   Journ.    Med.,    1888. 

29.  Sundry   Articles.      Cincinnati   Med.   Journ.,    1888. 

30.  Circumcision   from   a   Dermatological   Standpoint.      Lancet-Clinic,   Cincinnati,  xx,   p.   40,    1888. 

31.  Syphilitic    Ulceration    of    Nose.      Lancet    Clinic,    Cincinnati,    July,    1888. 

32.  Use   of   Arsenic   in   Dermatology.      Lancei-Clinic,    Cincinnati,    May   8,    1888. 

33.  Squamous   Eczema.      Lancei-Clinic,   Cincinnati,   xxi,   p.   493,    1888. 

34.  Psoriasis   Nummularis.      Lancei-Clinic,   Cincinnati,    Dec.    11,    1888. 

35.  Dermatological  Coverings  of  Animals  and  Plants.     Cincinnati  Nat.  Hisl.  Soc.  Journ.,  January, 
1888. 

36.  Treatment  of  Acne.      Trans.   Ohio   Stale   Med.   Soc,    1888. 

37.  Eczema    Infantile.    Trans.    Ohio    Stale    Med.   Soc,    1888. 

38.  Naevoid   Elephantiasis    (Case),   Cutaneous   Journal,    1888. 

39.  Rhinoplastes    and    Extrophy    Bladder.      Lancet-Clinic,    Cincinnati,    Nov.    9,    1889. 

40.  Eruption    (Hydrastus    and    Laudanum)    Lancet-Clinic,    March    18,    1889. 

41.  External    Urethrotomy.      Lancei-Clinic,    Cincinnati,    xxiii,   p.    583,    1889. 

42.  Plasto-Cosmetics   in   Surgery   of   Face.     Lancet-Clinic,   Cincinnati,   xxiii,   303,    1889. 

43.  Pemphigus    Vulgaris.      Lancet-Clinic,    Cincinnati,    xxiii,    470,    1889. 

44.  Cremation.      Med.    &  Surg.   Reporter,    Phila.,    March,    1889. 

45.  Lymphangitis.      Lancet-Clinic,    Cincinnati,    xxv,    597,     1889. 

46.  Fifteen   Cases   of   Gonorrhea.      Lancet-Clinic,  Cincinnati,   xxv.    11,    1890. 

47.  Copaiba   Eruption   Herpes   Lumbricales.      Lancet-Clinic,   Cincinnati,   xxv,   72,    1890. 

48.  Extensive   Naevus   in   a   Child   Three   Months   Old.      Lancei-Clinic,   xxv,    75,    1890. 

49.  General    Alopecia.      Lancet-Clinic,   Cincinnati,    xxv,    132,    1890. 

50.  Excision   of    the   Knee.      Lancet-Clinic,   Cincinnati,    xxv,    537,    1890. 

51.  Surgical    Treatment    of    Epilepsy.    Lancei-Clinic,    Cincinnati,    xxv,    73,     1890. 

52.  Radical  Operation   for   Hernia.      Lancet-Clinic,  Cincinnati,   xxvi,  41,    1891. 

53.  The  Use  and  Abuse  of  Soap  and   Water.      Cutaneous   Journal,  May,    1890. 

54.  Atypic  Herpes  Zoster  Gangrenosa.     Jour.  .4m.  Med.  Ass'n,  May,    1890. 

Page  One  Hundred  Twenty-Seven 


55.  External   Surgery  of   the  Nose.     Jour.  Am.  Med.  Ass'n,   May,    1890. 

56.  Indications   for   Infernal   Urethrotomy.      Trans.   Ohio   Slate  Med.   Soc,   May,    1890. 

57.  Large  Doses  of   Kali   lodidum,   St.  Louis   Med.  Mirror,    1893,  also  South   West.   Ohio   Med. 
Soc,   1890. 

58.  Experimental  Research  in  Bone  Grafting.      New  York  Slate  Med.  Assoc,  Nov.  5,    1890. 

59.  The  Removal  of  Lymphatic  Glands.      Cincinnati  Med.  Journ.,   March,    1890. 

60.  Osteo-penthesis  Reprint  from  Jour.  Am.  Med.  Ass'n,  xii,  277,   No.  2,  B.  Vol.  6,    1891. 

61.  A  Case  of  Talipes  Eqquino- Varus.     Jour.  Am.  Med.  Assn.,  August  20,    1892,  p.  305;    also 
Vol.  xii,   No.  2,   Bound,   Vol.  6. 

62.  Scrotal  Hernia.     Lancet-Clinic,  Cincinnati,  Vol.   7,  p.   16. 

63.  Early  Removal  of  Tubercular  Foci  of  the  Bone.     Jour.  Mat.  Med.,  xxi,  217,  No.    1,   Bound 
Vol.   6. 

64.  150   Circiimcisions.      Lancet-Clinic,    Cincinnati,   Feb.   9,    1892,    Bound    Vol.    5,   p.    135. 

65.  150    Circumcisions,    Lancet-Clinic,    Cincinnati,    v,    241,    1892. 

66.  Large   Doses   of   The   Iodides.     Lancet-Clinic,   Cincinnati.   Vol.    7,   p.   247. 

67.  The    Surgical    Treatment   of    Epilepsy.      Lancet- Clinic,    Cincinnati,   vii,    1891,   241. 

68.  A   Case   of   Sarcoma   Axilla.      Lancet- Clinic,   Cincinnati,   xxvi,   470,    1891. 

69.  Vesical    Calculus.      Lancet-Clinic,    Cincinnati,    xxvi,    471,    1891. 

70.  Fracture   of   the   Skull    and    Restoration   of    Fragments.      Lancet-Clinic,    Cincinnati,    xxvi,    729, 
1891. 

71.  Treatment  of  Chronic  Gonorrhea  with  Yellow-Oxide.     Lancet-Clinic,   Cincinnati,   xxvi,    1891. 

72.  Osteo-Penthesis,   Washington,   D.   C,   May,    1891. 

73.  The  Surgery  of  Cleft   Palate.     Miss.    Valley   Dental  Assoc.   Trans.,    March,    1891. 

74.  Observations  on   Koch's  Lymph   in   Sixty-Three   Cases.      Cincinnati  Academy   of   Med.,   Jan., 
1891,  also  Lancet-Clinic,  Feb.,   1891. 

75.  150  Circumcisions.      Lancet-Clinic,  Cincinnati,  xxviii,  359,    1892. 

76.  Abscess    of    Cerebellum    (6    cases)     Following    Caries    Middle    Ear    Disease.      Lancet-Clinic, 
Cincinnati,  xxviii,  818,    1892. 

77.  Neurectomy  Great  Sciatic,  Talipes,  Correction   (Photo).     Jour.  Am.  Med.  Ass'n,  May,   1892. 

78.  Internal  Urethrotomy    (36  cases).     New    York  Med.  Journ.,    July,    1893. 

79.  Niagara's  Water   Power.      Journ.   Cincinnati  Nat.  Hist.   Soc,  January,    1893. 

80.  Intestinal    Anastomosis    (Maunsell).      Jour.    Am.    Med.    Ass'n,    August    26,    1893. 

81.  Lupus,    Its    Extirpation.      A^en;     York    Med.    Journ..    September    23,    1893. 

82.  Varicocele    (19   Operations).      New    York   Med.   Jour.,    June    17,    1893. 

83.  Early  Removal  of  Tubercular  Foci  of  Bone.     Jour.  Mat.  Msdica,  May    12,    1893. 

84.  Primary  Gonorrhea  and   Syphilis   in  Children.     Jour.  Am.  Med.   Ass'n,   December    16,    1893. 

85.  Excision  of  Hip-Joinl  in  Tubercular  Disease.  Jour.  Cyn.  &  Pediatrics,  January,  1894, 
also  Cincinnati  Acad.  Med.,  November,   1893. 

86.  Obliteration    of    Pigmentation.      Jour.    Am.    Med.    Ass'n,    January    20,    1893. 

87.  External   Urethrotomy.      Med.   Record,   N.   Y.,  June,    1893. 

88.  A    Staff    of    Consultants.       Times    Star,    December    15,    1893. 

89.  Traumatic    Periostitis.      Railway    Age,    March    7,    1894. 

90.  Circular   Saw    Injury    (Photo).      Med.   News,    Phila.,   January    1.    1894. 

91.  Tubercular  Syphilis  Nose  (Photo)  Sarcoma  General  (Photos).  Cutaneous  &  Cenito-Urin. 
Journ.,  April    1,    1894. 

92.  Intestinal    Anastomosis.      Ann.   Surg.,    April    1,    1894. 

93.  Omental   Tumor,    St.   Louis,    1894. 

94.  Enchondroma  of   Neck    (Photos).      Times   &  Register,   January  6,    1894. 

95.  Last  30  of  a  Series  of  200  Circumcisions.     A^en.    York  Med.  Journ.,  March,    1894. 

96.  Six   Thigh   Amputations   and    Hydrocele.      IVest    Va.   Med.   Journ.,    September    1,    1894. 

97.  Small-pox    and    Vaccination.      Cincinnati    Med.    Journ.,    March,    1894. 

98.  Epithelioma   of   Lower   Jaw.      St.   Louis   Med.   Mirror,   April,    1894. 

99.  Extrophy   of    Bladder.      A^en;    York   Med.   Record,   April    14,    1894. 

100.  An    Interesting   Case    (Tubercular    Foci).      Mo.   Med.   Monthly,    April    1,    1894. 

101.  Epithelioma  Over  Sternum.     Med.  Progress,   Louisville,  Ky.,   May    1,    1894. 

102.  The   Surgical    Uses   of   Cocaine.      Med.    &   Surg.   Reporter,    April    14,    1894. 

103.  Fifty    Cases    of    Rectal    Surgery.      Journal   Rectal    Surg.,    Louisville,    Ky.,    July    1,    1894. 

104.  Hip- Joint  Amputation.      West    Va.   Med.  Jour.,   November,    1894. 

105.  The  Lengthening  and  Shortening  of  Bones.  L.  Oilier,  Lyons,  France.  Translated  by 
B.  M.   R.,   Cincinnati  Med.   Jour.,   March    1,    1894. 

106.  The  Removal  by  Trephine  of  Fluid  as  the  Result  of  Acute  Cerebral  Meningitis,  with 
Report  of  a  Case  and  Experiments  Upon  the  Lower  Animals.  New  York  State  Med.  Ass'n,  October, 
1894. 

107.  New   Surgery    in    the    So-Called   Medical   Cases.      Marion,    Ohio,    December   21,    1894. 

108.  Ccistration  for  Hypertrophied  Prostate.     December  2,    1894. 

109.  Removal  of  Head  of  Femur   From  Lesser  Sciatic   Notch.     December   15,    1894. 

110.  Trephine    in   Acute    Cerebral    Meningitis.      December    8,    1894. 

111.  Colotomy    and    Kraske    Operation.      Cincinnati    Lancet-Clinic,    xxxiii,    679. 

112.  Hydrocele   Radical   Operation.      IVest    Va.   Med.   Jour.,   October,    1894. 

113.  Hygroma.     Cincinnati  Acad.   Med.,   December    11,    1895;    also  Lancet-Clinic,  xxxv,   724. 

Page  One  Hundred  Twenty-Eight 


114.  The    ManaRemenI   of   Tubercular   Subjects.      Penna.   Soc,    May    14,    1895. 

115.  Dislocation  and  Double  Fracture  of  Upper  Third  of  Humerus.  Jour.  Am.  Med.  Ais'n. 
May,    1895. 

116.  Malignant  Growths  of  Superior  Maxillary  Bone.     5/.  Louis  Med.  Mirror,   March    I,    1895. 

117.  Modern  Surgery  of  Serous  Cavities.  Nat.  .'\ss'n  Railway  Surgeons  Centr.  Ohio,  Med.  Soc, 
Columbus,  Ohio,  February  7,   1895. 

118.  Cerebral  Cyst   Removal  Typhoid   Ulcer  Operation.      Cincinnali  Lancet-Clinic,   April  6,    1895. 

119.  Flat  Foot,  Its  Correction  and  Comparative  Study  With  the  Foot  of  the  Orang,  Chimpanzee, 
Gorilla   and    Baboon.      Am.    Med.    Ass'n,   August  3,    1895. 

120.  Double   Club   Fool   and    Hands,   Children's   Section.      Am.   Med.   Ass'n    Journal,    October    10, 

121.  Lupus   Treated   by   Galvanism.      Am.   Med.   Assn.  Journ.,    May   7-10,    1895. 

122.  Reply  to  Medical  Record  Editorial  on  Circumcision.  Med.  &  Surg.  Reporter,  Phila., 
February  21,    1895. 

123.  Site  of  Inoculation   (Vaccinia)  Lancel-Clwic,  Cincinnati,  April  20,   1895. 

124.  Neuralgia  of  the  Fifth  Nerve.     Cincinnati  Acad.  Med.,   March,    1895. 

125.  Rupture  of  the  Left  Lateral  Ventricle.     Cincinnati  Acad.  Med.,  April,    1895. 

126.  New    Operation    for    Hemorrhoids   and    Prolapsed    Rectum.      Ph};s.    &   Surgeon,    Ann    Arbor, 

October,    1895.  .„    ,     -  c  ,.      .one 

127.  The  Cranectomies.      Brain   Surgery.      Read    Before   Detroit   Med.   hoc,   Sept.    16,    18^:3. 

128.  Exsection  of  Head  of  Humerus  and  Jaws  for  Ankylosis.     Lancet-Clinic,  Cincinnati,  Oct.  20, 

129.  The  Removal  of  Lymphatic  Glands.      Cincinnali  Med.  Journ.,  March,    1890. 

130.  A  Radical  Operation  for  Prolapsed  Rectum  and  Hemorrhoids.  Chicago  Academy  Medicine, 
Feb.    14,'  1896. 

131.  The   Advantages   of    the    Bicycle.      Cincinnati    Tribune,    Oct.   6,    1895. 

132.  Enchrondritis,  Surgical  Treatment.     Journ.  Am.  Med.  Assn.,  Aug.  22.    1896. 

133.  Sanitation  of  Workshops  and  Public  Conveyances.     Lancet-Clinic,  Cincinnati,  1896,  xxxvi,  396. 

134.  Vivisection.       Cincinnali    Commercial    Gazelle,    November     10,     1895. 

135.  Anal    Fistula    Peritonitis    Laparotomy    Recovery.      Lancel-Clinic,    Cincinnati,    April    7,    1896. 

136.  Surgery   of    the  Chest.      Report   of   Cases.      Lancet-Clinic,    Cincinnati,    1896,   xxxvii,   237. 

137.  Twelve  Deaths. — Total  Number  of  Fatalaties  in  12  Years  (1)  Strangulated  Omental  Tumor; 
(2)  Sarcoma  of  Lower  End  of  Femur;  (3)  Colotomy;  (4)  Intestinal  Anastomosis;  (5)  Post.  Dislocation 
of  Femur;  (6)  Typhoid  Ulcer;  (7)  Appendicitis;  (8)  Cystic  Kidney;  (9)  Tuberculosis  Sacro- Iliac; 
(10)    Hip-Joint  Amputation;    (11)    Two  Trachectomies,   Lancet-Clinic,   Cincinnati,    1896,   xxxvii,   264. 

138.  Trifacial  Neuralgia,  Ligation  of  CommoiT  and  External;  Cartoid  Report  of  Case  97  Years 
of   Age;    Virginia   State   Med.   Soc,   Rockbridge.   Alum   Springs,   September  8-10,    1896. 

139.  Sulgical  Melange:  (1)  Ligation  of  Brachial;  (2)  Gunshot  "Wound  of  Facial  Artery;  (3; 
Talipes;  (4)  Hyperlrophied  Prostate,  3  cases;  (5)  Sarcoma  of  Sacrum,  Miss.  Valley  Med.  Assn., 
September  15,  1896. 

140.  Eczema   Chronicum    and    Ethyl   Chloride    (Bougie).      Lancel-Chmc,    Cincinnati,    1896,   xxxvu, 

141.  Brachial  Cysts,  Extirpation,  Recovery.  Lancel-Clinic,  Cincinnati.  1896,  xxxviii,  36  Dis- 
cussion 40.  o        n/I         1         D 

142.  Surgical  Melange.  (1)  Craniotomes;  (2)  Thacheolomy  Lacehook;  (3)  Murphy  Button 
Gut  Strangulation;  (4)  Appendicitis  Suppuration,  4  Cases;  (5)  Tubercular  Fibula  .Amputation;  (6) 
Amputation  Middle  Thigh.     Read  before  North  East  Med.  Assn.  Kentucky,  Carlisle,  January  21,    1897. 

143.  Ligation  Common  Cartoid  for  Trifacial  Neuralgia.  Surg.  Seel.,  Jour.  Am.  Med.  Assn., 
June    1-5,    1897. 

144.  Cranectomies,   Report   of    Four   Cases.      Lancel-Clinic,    Cincinnati,    July    10,    1897. 

145.  Removal  of  Upper  and  Lower  Jaws  Through  the  Mouth  Without  Incision.  Railway  Surg., 
Chicago,   1897-8,  IV,  337. 

146.  Appendicitis,  4  Cases.     Lancel-Clinic,  Cincinnati,  July    17,    1897. 

147.  Rectal  Prolapse  Hemorrhoids.     Mitchell  Dist.  Med.  Soc,  July  8-9.   1897. 

148.  Appendicitis.     Olympic  Springs  Bath  Co.,  Ky.,  July    10,   1897. 

149.  Brain    Surgery    for    Epilepsy.      Milrvaukee    Med.    Jour.,    1896,    iv,    92-94. 

150.  Trifacial  Neuralgia,  Ligation  of  Common  Cartoid  and  External  Cartoids.  Report  of  a 
Case  aged  97  years.      Virginia  Med.  Semi-Monthlv,   Richmond,    1896-7,   i,   326-328. 

151.  Three    Cases   of    Appendicitis.      Lancel-Clinic,    Cincinnali,    1897,    xxxix,    330-332. 

152.  Lace   Hook   in   Trachea,   Tracheotomy.      Columbus   Med.   Journ.,    1897,   xviii,   586. 

153.  Foreign    Body    in    Trachea.      Lancet-Clinic,    Cincinnati,     1897,    xxxviii,    139. 

154.  Abdominal    Incision   for  .Ascites.      Lancet-Clinic,  Cincinnati,    1897,  xxxix.   347. 

155.  Aneurism  of  Aortic  Arch.  Surgical  Treatment  by  Ligation  of  Right  Common  Cartoid  and 
Sub-Clavian   Arteries.     Journ.   Am.  Med.   Assn.,   August    13,    1898. 

156.  Deaths,  Surgical  Causes:  (I)  Gangrene,  Thigh  Amputation;  (2)  Brain  .Abscess;  (3) 
Ovarectomy,  Double;  (4)  Intestinal  Obstruction;  (5)  Fibro-Sarcoma  of  Uterus;  (6)  Lithotomy;  (7) 
Gall-Bladder  Rupture;  (8)  Brain  Abscess;  (9)  Fracture  Base  of  Skull;  (10)  Meningitis  Cerebral. 
/.ance/-C/m/c,   C.ncmnati,    1898,   xl,   571-575.  .-    ,      o 

157.  Trifacial  Neuralgia,  Ligature  Externa!  and  Common  Cartoid.  Ohio  State  Med.  Soc, 
May  4-6,  1898. 

Page  One-Hundred   Twenty-Nine 


158.  Hypertrophied    Prostate,    Nine    Cases.      Lancel-Clinic,    Cincinnati,     1898,    xl,    481. 

159.  The  Dermal  Coverings  of  Animals  and  Plants.  A  Short  Resume  of  Various  Authors, 
Lancet-Clinic,    Cincinnati,    August   20,    1898. 

160.  Serpents  and  Their  Venom,  Copperhead,  Corral  and  Rattlesnake.     Lancet-Clinic,  Cincinnati, 

1898,  xli.  491-494.  "^ 

161.  Surgical  Melange;  (I)  Empyema  of  Chest;  (2)  Empyema  of  Chest;  (3)  Abscess  of 
L.ung;  (4)  Ununited  Fracture  of  Humerus;  (5)  Septum  Nasi  Protrusion;  (6)  Septum  Nasi  Protrusion; 
(7)  Sarcoma  of  Neck;  (8)  Sarcoma  Popliteal  Space;  (9)  Anal  Fistula;  (10)  Anal  Fistula;  Lancet- 
Clinic,  Cincinnati. 

162.  Case  History,    Photograph.      Dermatological   Section,   .'\m.   Med.   Assoc,   June   6-9,    1899. 

163.  Surgical   Appendicitis.      Ohio   Stale   Med.    Soc.    May,    '899,   Vol.   xii,   p.   221. 

164.  Heart  of  Tortoise.      Virginia  Med.  Monthlv,  March   10,   1899. 

165.  Rectal    Sarcoma,    Excision    and    Subsequent    Colotomy.      Am.    Proctological    Assoc,    June    6, 

1899. 

166.  Cranial    Injuries   of   Childhood,   Their   Treatment.      Ohio    Pediatric   Soc,    May   9,    1899. 

167.  Cholangiostome,    Presented    to   New    York    Soc.    Med,    Assoc,    December   25,    1899,    Vol.    v, 

No.  12,  p.  895. 

168.  Femora!  A.rtery  and  Vein,  Their  Destruction  With  Loss  of  Leg.  Journ.  Am.  Med.  Assn., 
August,    1899. 

169.  Dermatology,  A  Record  of  Clinical  Cases,  Cincinnati,  1893.  A  Report  of  300  Dermatological 
Cases,  1899;  Record  of  Smallpox  Cases  in  Ironton,  March  15,  1881  to  June  15,  1882.  Notes  of 
Lectures  on  Medicine,  Translation  of  Dr.  Ollier's  work. 

170.  Handbook:      What  To   Do    In    Case   of    Accident.       1893. 

171.  An   Operation   for   Inguinal   Hernia.      Lancet-Clinic,    1898,   ns.   xli,    508. 

172.  Sarcoma  in  Patients  With  a  History  of  Syphilitic  Infection.  Lancet-Clinic,  Cincinnati,  1898, 
ns.   xli,   456-458. 

173.  A  Case  of  Ununited  Fracture  of  the  Humerus.     Lancel-Clinic,  Cincinnati,   1898,  ns.  xli,  508. 

174.  Translation  of  Dr.  OHiers  Work.     Bone  Resection. 

175.  Specimens  Demonstrating  the  Operation  of  Gastro  Cholecystotomy ;  End  to  End  Anastomosis 
of   Gut,   etc.,   Bound   Vol.,   ii,   p.   302. 

176.  Report  of  a  Case  of  Talipes  Equino-Varus.  Jour.  Am.  Med.  Assn.,  Vol.  9,  No.  8,  d. 
219,    Bound    Vol.    ii. 

177.  Circumcision,  Last  50  of  Series  of  200.  New  York  Med.  Journ.,  April  7,  1894,  p.  431. 
Bound  Vol.  49. 

178.  Bloodless  Amputation   at   the   Hip-Joint.      Bound  Vol.   iii,   p.  32,    1898. 

179.  Direct  Fixation  of  Fractures.  Medical  Age,  Detroit,  1894,  1.717.  Railwa])  Surgeon. 
Chicago,   1894,   1.  351.     Times  Register,  Phila.,  xxviii,  306-308,   1894.     Also  Reprint. 

180.  Operations   for  Gall-Stones.      Lancet-Clinic,   Cincinnati,    1899,   ns.   xiii,   237-239. 

181.  Sarcome  de  la  Resion  anlerieure  du  Thorax  et  de  I'aisse  lie  droit,  J.  Am.  Med.  Assn., 
1900,  xxiv,  76-77,   1   fig. 

182.  Ovarian  Pregnancy.  Report  of  a  Case  at  Full  Term.  Am.  J.  Surg.  &  Gynecol.,  St.  Louis, 
1900,   xiii,    146-148. 

183.  Specimens   of   Gall-Stones.      Lancet-Clinic,   Cincinnati,    xliv,    369-370. 

184.  Specimens   of   Gall-Stones.      Lancet-Clinic,   Cincinnati,    1900,   xlv,   594. 

185.  Case   of    Ectopic    Pregnancy.      Lancel-Clinic,    Cincinnati,    1900,    xliv,   370-371. 

186.  Sarcoma   of   the   Kidney.      Lancet-Clinic,   Cincinnati,    1900,   xliv,   364. 

187.  Submucous    Ligature    For   Rectal    Hemorrhoids    and    Prolapse.      Med.   Rev.    of   Rev.     N     Y 

1900,  vi,  512-519,  6  fig. 

188.  Some  Anomalies   of    the   Uterus.     Lancel-Clinic,   Cincinnati,    1901,   xlvii,   554. 

189.  Hernia,  Radical  Operation  with  Wire  Mattress  (Phelps)  Trans.  New  York  State  Med 
Soc,   1901. 

190.  Inguinal    Hernia.     Lancet-Clinic,   Cincinnati,    1901,   ns.   xlvi,    105. 

191.  Appendicitis    (Surgical    Treatment).      Lancet-Clinic,    Cincinnati,    1901,    ns.,    xlvi,    189-192. 

192.  The  Appendix  Veriformis  and  Caecum.  A  Comparative  Study.  1814-1901  /  Am  Mpd 
Assn.,   1901,  xxxvi,   1556.  ■     •'■  ■ 

193.  Discussion  on  Specimens  of  Tubercular  Kidney  and  Bladder.  Lancet-Clinic,  Cincinnati,  1902 
ns.  xlix,  39. 

194.  A  Brief  Resume  of  the  Treatment  of  Tuberculosis.     Lancet-Clinic,  Cincinnati,   1902    ns    xlix 

140-141.  '  '      •        . 

195.  Surgery  of  the  Prostate  and  Diaphragm.     Lancel-Clinic.  Cincinnati,    1902    ns    xlix    369-376- 

399-405;   431-434.  .        ,  , 

196.  Appendicitis.      Lancet-Clinic,    Cincinnati,     1902,    ns.    xlviii,    573-576. 

197.  Surgery  of   the  Heart.     Lancet-Clinic,  Cincinnati,    1902. 

198.  Ligation    of    Arteries,    Cocaine    Anaesthesia.      Interstate    Med.    Journ.,    St.    Louis,     1902,    ix. 

199.  Ligation  of  Arteries,  Cocaine  Anesthesia.     Lancet-Clinic,  Cincinnati,   1902,  ns.  xlviii,  403-405. 

200.  Surgery  of  Penetrating  Wounds  of  Lungs  and  Heart  (Experimental)  Virginia  Med.  Semi- 
Monthly,  Richmond,  Va.,  1902-3,  vii,  508-511. 

201.  Exhibition  of  a  Patient  Upon  Whom  Operation  for  Floating  Kidney  Was  Performed. 
Lancet-Clinic,  Cincinnati,    1903,   ns.    50,   p.   63. 

Page    One   Hundred   Thirty 


202.  Specimen  of  Foreign  Body  Removed  From  ihe  Intestine,  Supposed  to  be  a  Piece  of  Carbon. 
/.anccl-Clinic,  Cincinnati,    1903,   ns.   50,   p.  63. 

203.  Lung    Surgery.      Laiicel-Clinic,    Cincmnati,    1903,    ns.    \'oi.    50,    p.    1-9. 

204.  Lung  Surgery,  Historical  and  Experimental.  Abstract  Med.  News,  New  York,  1903,  Ixxxiii, 
683-699. 

205.  Surgeiy  of  the  Pancreas  (Historical  and  Experimental).  Med.  Forlnightly,  St.  Louis,  1903, 
xxiii,   299-305. 

206.  The  Surgery  of  the  Heart.     N.   Y.  Med.  Journ.,   1903,  Ixxvii,  918-963;    1148-1204. 

207.  Typhoid  Gangrene  of  the  Lower  Extremities,  134  Cases  of  Spontaneous  and  Surgical  Am- 
putations;   An   Flistorical   Resume.     Lancet-Clinic.  Cincinnati,    1903,   ns.   Vol.   51,   pp.  553;    580. 

208.  Surgery  of  the  Thyroid.     Kansas  Cr/p  Med.  Index,— Lancet,  1903,  xxiv,  389-436. 

209.  Surgery    of    the    Diaphragm.      Virginia    Med.    Semi-Monlhl\j,    Richmond,    1903-4,    viii,    87-90. 

210.  Typhoid  Gangrene  of  the  Lower  Extremities,  134  Cases,  Spontaneous  and  Surgical  Am- 
putations;   An  Historical  Resume.     Buffalo  Med.  Journ.,    1903-4,  ns.   xliii,   361-364. 

211.  Ibid-Columhus   Med.   Journ.,    1904,    xxviii,    11-13. 

212     Ibid-Med.   &   Surg.  Monitor,   Indianapolis,    1904,   vii,   28-30. 

213.  Ihid-Am.  journ.   Surg.   &■   Cynec,   St.   Louis,    1903-4,   xvii,    117. 

214.  I  bid -Denver  Med.    Times,    1903-4,   xxiii,   382-385. 

215.  Ibid- Virginia   Med.   Semi -Monthly;,    Richmond,    Va.,    1903,   xiii,    562-564. 

216.  Surgery  of  the  Prostate,  Pancreas,  Spleen,  Diaphragm,  Thyroid  Gland  and  Hydrocehpalus 
(Volume)    1904. 

217.  Surgery  of  Hydrocephalus.  An  Historical  Review.  Am.  Med.,  Philadelphia,  1904,  vii, 
783-787. 

218.  Surgery   of    Hydrocephalus.      Col.   Med.   Journ.,    1904,    xxviii,    64-67. 

219.  The   Surgery  of   the   Heart   and   Lungs,   etc.,   New   York,    1904,   pp.   562,    132   plates. 

220.  Cholecystotomy.       Lancet-Clinic,    Cincinnati,     1904,    ns.     liii,    432. 

221.  Excision  of  Elbow  Joint  for  Traumatic  and  Inflammatory  Arthritic  Ankylosis.  Am.  Journ. 
Surg.  &•  C^nec,  St.  Louis,   1904-5,  xvii,    134-138;    also  Louisville  Journ.  Med.  &  Surg.,    1904-5,  xi,  318. 

222.  Fracture  Deformities  of  the  Lower  Leg  in  Childhood.  Illustrated  by  Skiaeraphs.  5/.  Louis 
Med.  Rev.,   1905,  lii.  524-544. 

223.  Rupture  of  the  Gall-Bladder,  Spontaneous  and  Traumatic,  With  and  Without  Operation. 
An  Historical  Review  of  273  Cases.     5/.  Louis  Med.  Rev.,   1905,  li,   108-233-276-456-476-497;   lii,  4.  25. 

224.  Excision  of  the  Elbow  Joint  for  Traumatic  and  Arthritic  Ankylosis.  Abstract.  5/.  Louis 
Med.  Rev.,   1905,  li,  437,  also  Trans.   West  Surg.  &  Cynec.  Assoc,   1905. 

225.  Cholecystotomy  and  Nephrectomy  for  Gall-Stones  and  Pyonephrosis  (Tubercular).  Lancet- 
Clinic,  Cincinnati,   1905,  ns.  liv,   139. 

226.  Vesico-Rectal   Anastomosis.     New    Y or\  Med.  Journ.,    1905,   Ixxxi,    162. 

227.  Ovarian  Angeioma.     A'en;   Y or}(  Med.  Journ.,   1905,  Ixxxi,   163. 

228.  Dr.  Tuholske's  Case  of   Malformahon  of   the   Bladder.      Si.  Louis  Med.  Rev.,    1905,   li,    178. 

229.  Specimens    of    Tubercular    Kidneys.      Lancet-Clinic,    Cincinnati,     1905,    ns.    liv,    532. 

230.  Haematoma    of    the    Ovary.      Lancet-Clinic,    Cincinnati,    1905,    ns.    liv,    687. 

231.  Diagnosis  and  Treatment  of  Gall-Stones.     Kentucify  Med.  Journ.,  Louisville,    1905-6,  iii,  550. 

232.  Cardiac  Stimulation  for  Suspended  Animation  by  Direct  Digital  Manipulation.  .A  Supple- 
mentary Report  to  Surgery  of  the  Heart  and  Lungs  (Abstract).  Col.  Med.  Journ.,  1906,  xxx,  308-311, 
also  Colorado  Med.  Journ.,    1906,  xii,  325-328. 

233.  Cardiac  Stimulation  for  Suspended  Animation  by  Direct  Digital  Manipulation,  Illustrated 
by  Diagrams  and  Case  Reports.  Am.  Med.  Comp.,  Toledo,  1906,  xix.  177-180,  Buffalo  Med.  journ., 
1905-1906,  Ixi,  708. 

234.  Trigemnial  Neuralgia,  Surgical  Treatment.  An  Historical  Resume.  Lancet-Clinic,  Cincinnati, 
1906,  ns.  Ivi,  597-608;  also  Nashville  Journ.  Med.  &  Surg.,  1906,  xcviii,  97-101;  also  Virginia  Med 
Semi-Monthly,    Richmond,     1906-7,    xi,     12-14. 

235.  The  Diseases  Diagnosis  and  Surgical  Treatment  of  the  Right  Upper  .Abdominal  Cavity.  An 
Historical    Resume.      Lancet-Clinic,   Cincinnati,    1906,   Ixvi,   201-242. 

236.  Cardiac  Stimulation  for  Suspended  Animation  by  Direct  Digital  Manipulation.  Med.  Rev. 
of  Rev.,  New  York,   1906,  xii,  848-850. 

237.  Ibid — Trana.  Surg.  Sect.  Am.  Med.  Assn.,    1906,  Volume. 

238.  Feminalities.     Lancet-Clinic,  Cincinnati,    1907. 

239.  Limiting    Population.      Lancet-Clinic,    Cincinnati,    1907. 

240.  Villous    Papilloma    of    the    Rectum.      New    Ynrl(   Med.   Journ.,    1907,    Ixxx. 

241.  Surgery  of  the  Ureter.  St.  Louis  Med.  Rev..  1907-8,  Serial  Bound  Volume,  300  Copies. 
An    Historical    Review.       1908. 

242.  An    Historical    Review   of    Papilloma   and   Adenoma.      American   Journ.   Dermatology     March 

1,   1908. 

243.  Appendicitis  and    Typhoid  Fever,  Four  Cases.     Lancet-Clinic,  Cincinnati,   February  22,    1908. 

244.  The  Disposition  of  the  Appendicular  Stiimp.     Lancet-Clinic,  Cincinnati,   March   28,    1908. 

245.  Intestinal  Obstruction  Exploration,  Western  Surgical  and  Gynecological  .A.ssociation  (trans.), 
St.  Louis,  Mo.,  December  30-31,    1907. 

246.  Capillary  Varicosity  of  Rectal  Mucosa.  .Am.  Proctologic  .A.ssn.  (Trans.),  Chicago,  June  I. 
1908. 

Page    One    Hundred    Thirty-One 


247.  Surgery  of  Hare  Lip  and  Cleft  Palate   (Illustrated).      Trans.  Ohio   Valley  Med.  Assn.,    1908. 

248.  Protracted  Birth  of  Second  Intra-Uterine  Twin.  A  Resume,  Biologically  Considered.  Trans. 
Miss.    Valley  Med.  Assn.,    1908. 

249.  Surgery  of  the  Prostate,  Pancreas,  Spleen,  Diaphragm,  Thyroid  and  Hydrocephalus  (A 
Resume)    500  Bound  Autograph  Copies.     250  pp.  each,    1904.  ^ 

250.  Radical   Cure   for  Hernia.     Lancet-Clinic,   ns.   xxvi,    1891. 

251.  Eczema   Infantile.     Journ.  Am.  Med.   Assn.,   xix,    1892. 

252.  Report  of  Twelve  Cases  of  Herniotomy.      Lancel-Clinic,   ns.   xxviii,    1892. 

253.  Psoriasis,  Forty  Cases  Treated  With  Arsenious  Acid.     Journ.  Am.  Med.  Assn.,  xx,  482,  1892. 

254.  Direct  Fixation  in  Fractures.      Times  and  Register,  Philadelphia,  xxviii,    1894. 

255.  Prostate.      Times  and  Register,  Philadelphia,  xxix,    1894. 

256.  Typhoid  Perforation,  Cerebral  Cyst.      Lancet-Clinic,  ns.  xxiv,    1895. 

257.  Brain   Surgery    for   Epilepsy.      Lancet-Clinic,  ns.   xxxv,    1895. 

258.  Case   Reports.      Lancet-Clinic,   ns.   xxxv,    1895. 

259.  Removal  of  the  Head  of  the  Femur  From  the  Lesser  Sciatic  Notch.  Med.  Fortnightly,  St. 
Louis,  vii,   1895. 

260.  Rectal  Carcinoma  with  Subsequent  Cololomy;  Normal  Prophylactic  Appendectorr.y.  Si. 
Louis  Med.  Revierv,  xli,    1900. 

261.  Surgery  of  Congenital  Dislocation  of  Head  of  Femur.  Western  Surg.  &  Gyn.  Assn.  Trans. 
December  20-21,    1909;    also  New    York  Med.  Journ.,  January  4,    1910,  p.    1154. 

262.  Spastic   Contraction   of   Uterus.      Lancet-Clinic,   October   16,    1906. 

263.  Local  Versus  General  Anaesthesia.  Miss.  Valley  Med.  Assn.,  St.  Louis,  Oct.  12-14,  1909, 
also  Lancet-Clinic,   Oct.    23,    1909,    pp.   235-247:    also    Tables    in    Medical    Review    of   Reviews,    Dec, 

1909,  pp.  828-834. 

264.  The  Prostate.  Dark  County  Ohio  Med.  Soc,  Seot.  9,  1909,  also  A'en;  York  Med.  Jour., 
Jan.  29,  pp.  225-227,  1910. 

265.  Civilization,  Yesterday,  Today,  Tomorrow.  The  First  of  a  Series  of  Addresses  Delivered 
Before  the  Medical  Dept.  of  Barnes  University,  St.  Louis,  Mo.,  Oct.  13,  1909;  also  5/.  Louis  Med. 
Rev,,  Dec,  pp.  393-399,  1909. 

266.  Surgery  of  Cirrhosis  of  the  Liver.  Cincinnati  Acad.  Med.,  Feb.  18,  1909;  also  New  York 
Med.  Journ.,  Feb.  18,  1909. 

267.  Odontomata.     Cincinnati   Acad.  Med.,  Nov.,    1908;    also  Lancet-Clinic,  Jan.  9,    1909. 

268.  Anatomy  and  Pathology  of  Ureter.  New  York  Acad.  Med.,  Dec.  17,  1908;  also  Virginia 
Semi-Monihly  Med.  Journ.;  also  New   York  Med.  Journ.,  Jan.,   1909. 

269.  Malformation  and  Amputation  of  Sigmoid  and  Lesions  to  and  Behind  the  Left  Broad  Liga- 
n,ent;   Illustrated.     Ohio  State  Med.  Soc.  Trans.,   1909;  also  Ohio  State  Med.  Soc.  Journ.,  May  15,  1910. 

270.  Sterilization  for  Crime.  May  15-28.  Sent  this  Paper  to  Literary  Digest,  Saturday  Evening 
Post  and  New  York  Med.  Journ.  (all  refused  it).  Published  in  Med.  Review  of  Reviews,  New  York, 
Nov.  25,  p.  755,   1909. 

27  i.  Local  Versus  General  Anaesthesia.  Kentucky  Med.  Soc,  Torrent,  Ky.,  June  20-21,  1909; 
also    Piqua,    Ohio,    Sept.    20,    1909. 

272.  Surgery  of  Cleft  Palate.  Read  French  Lick  Springs,  Indiana,  Oct.,  1909;  also  Ohio 
Valley  Med.  Assn.;    also  Lancet-Clinic,  Aug.   28,    1909. 

273.  Surgery  of  the  Thorax  and  Its  Viscera.  Second  Address,  Barnes  Med.  College,  St.  Louis, 
Dec,   1909;   also   Virginia  Med.  Semi-Month.,  Richmond,  Va.,  May   13,  p.  65-70,   1910. 

274.  Case  Reports  of  Multiple  Surgical  Operations.     Indianapolis  Med.  Jour.,  May,  p.  212,    1910. 
Haematoma  Right  Broad  Ligament  Complicating  Three  Months'  Gestation.     St.  Louis  Med    Review 

Oct.    1,   1910. 

275.  Anomalous  Kidney  (Nephrectomy)  ;  Illustrated.  Jour.  Surg.  Cvn.  &  Ohsi  Tune  n  637- 
638,   1910.  ^  •'   J        '   P-   u^/ 

276.  Community    Education.      Lancet-Clinic,   June   25,    1910. 

277.  The  Newer  Surgery.  An  Address  Before  the  Tri-State  Med.  Soc,  Iowa,  Illinois  Missouri 
St.  Louis,   Mo.,   Sept.    13-14,    1910;    also  Lancet-Clinic,  Oct.    15,    1910. 

278.  Surgery  of  Aneurysm  of  the  Aortic  Arch  and  Its  Branches;  Illustrated.  Read  Before  Chicaoo 
Med.  Soc,   Feb.    16,    1910;    also  Lancet-Clinic,   Aug.  27,  p.    196-207,    1910. 

279.  Discussion  of  Dr.  Deaton's  Paper,  Rectal  Colonic  Tube.  fourn.  Ohio  State  Med  Soc 
Jan.,  p.   29,    1910. 

280.  Surgery  of  the  Posterior  Urethra,  and  Prostatic  Abscess  and  Their  Consequent  Fistulac. 
Read  Before  the  North  Central  Soc.  of  the  Am.  Uroloeical  Assoc.  With  the  Chicano  Uroloc  Soc 
March  24,    1910;    also  Am.  Journ.  Surg.,  p.  214,  July    10,''l910. 

Two  Cases  of  Twenty-Pound  Sarcoma  of  the  Left  Ovary.     St.  Louis  Med.  Review,  Oct.    1,    1910. 

281.  Surgery  of  the  Great  Sciatic  Nerve,  Including  Two  Cases  of  Complete  Severance  with  Sub- 
sequent Anastomosis.     Miss.  Valley  Med.  Assn.,  Detroit.  Sept.    13-15,   1910-    also  Lancel-Clinic    Oct     1 

1910.  '        ■     ' 

282.  Intra-Peritoneal  Exploratorv  Hysterotomy.  Read  Before  Cincinnati  Acad.  Med  fan  17 
1910,  also  Lance/-C/mi'c,  March  26.  pp.  339-341,   1910.  '  ' 

283.  Surgical  Contraindications.  Read  Before  the  Union  Med.  Assn.,  Richmond  Ind  April 
27,   1911;    also  Lunce(-C/ini'c,   May  6,    1911. 

284.  Naphtha  Soap,  Its  Dangers.     5/.  Louis  Med.  Rev.,  Aug.   1,   1911. 

Page   One   Hundred    Thirty-Two 


285.  Civilization  Yesterday,  Today,  Tomorrow.     An  Address.     5/.  Louis  Med.  Rev.,  Dec,    1900. 

286.  Thoracic    Surgery.      Lancet-Clinic,    Nov.   26,    1910. 

287.  The   Thorax.     Lancci-Clinic,  July   29.    1911. 

288.  Surgery   of    the    Pleura.      Lancet-Clinic,    p.    310-320,    Sept.   23.    1911. 

289.  Naphtha    Soap.    Its   Dangers.      St.   Louis    Med.   Reviem,   July    1,    1911. 

290.  Surgery  of   the  Lung.     Lancet-Clinic,  pp.   393-398,  Oct.    14.    1911. 

291.  Surgery  of   the  Lung.     Lancet-Clinic,  pp.  441-443.  Oct.  28.    1911. 

292.  Surgery  of   the  Lung.     Lancet-Clinic,  pp.   503-504,   Nov.   4,    1911. 

293.  Surgery    of    the    Bronchus.      Lancet-Clinic,    pp.   603-607.    Dec.   9,    1911. 

294.  Thymus,  Vagi  and  Ductus  Thoracicus.  Demonstrated  on  a  Dog  by  Intratracheal  Insufflation 
Before  The  Western  Surgical  and  Gynecological  Association.  Kansas  City,  Mo.,  Dec.  19,  1911.  Trans- 
action  for   same,    and   International   Clinics,   Vol.    iv.    22nd  Series.    1912. 

295.  Surgery   of   the   Pericardium,   Lancet-Clinic,   Cincinnati,    1912. 

296.  The  Coccyx  as  a  Causative  Factor  in  Genito-Urinary  Diseases.  Read  Before  The  North 
Central   Branch  of  The  .American  Genito-Urinary  Association,  St.   Louis,  Mo.,  Feb.   5,   7,    1912. 

297.  Intratracheal  Insufflation.  Medical  Record,  Sept.  19,  1914.  Delivered  at  the  New  York 
Polyclinic.    International    Congress    of    Brussels    of    1914. 

298.  Suprapubic  Cesarian  Section  for  Puerperal  Eclampsia.  Trans.  West.  Sur".  and  Cyn.  Asso., 
1913;   also  Reprint  The  American  Journ.  of  Surgerv,  Sept.  and  Oct.,   1914. 

299.  Intratracheal  Insufflation  Anesthesia  Demonstration  on  Dog.  Alabama  State  Med.  Soc, 
Montgomery,    Ala.,    Transactions,    1914. 

300.  Surgery  of   the  Thorax  and   Its  Viscera.     .A  Volume  of   700  pages.      1916. 

301.  Intratracheal    Insufflation    (History).      Amer.   Jour,   of   Surg.,   Oct.,    1915. 

302.  Anesthesia  From  the  Dawn  and  Its  Relation  to  Surgery.  Lancet-Clinic  Cincinnati  Nov 
28,    p.    484,    1915.      (An    Illustrated    Address.) 

303.  Chloacal  Morphology.  Amer.  Genito-Urinary  .Asso.,  Chicago,  Nov.  I2-I3tli,  1915.  (Trans- 
actions.) 

304.  Local  Anesthesia.  An  Illustrated  Address.  West  Virginia  State  Med.  Asso  Huntinofon 
W.   Va.,    May    12th,    1915.  nungton, 


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